table of contents · revised: 09/30/13 update # 13-11 page 2 medi-cal handbook table of contents...

Medi-Cal Handbook page TC-1 Table of Contents

Table of Contents

1. Medi-Cal Overview (Heirarchy)........................................................................1-1

1.1 Cash Grant Programs ....................................................................................1-1

1.2 Family-based Medi-Cal ..................................................................................1-1

1.3 Presumptive Eligibility for Pregnant Women ..................................................1-1

1.4 Continued Eligibility for Pregnant Women and Children [50201, 50203, 50227]1-2

1.5 Special Percent Programs for Pregnant Women and Children ......................1-2

1.6 “Safely Surrendered Baby Law” formerly known as “Safe Arms for Newborns Law.................................................................................................................1-31.6.1 Scope of Medi-Cal Coverage ..........................................................1-31.6.2 Period of Eligibility ...........................................................................1-31.6.3 Confidentiality..................................................................................1-41.6.4 Processing Medi-Cal Applications...................................................1-4

1.7 Transitional Medi-Cal .....................................................................................1-4

1.8 Aged, Blind or Disabled..................................................................................1-5

1.9 Medicare Savings Programs (MSP) ...............................................................1-5

1.10 Percent Programs for Aged, Blind and Disabled............................................1-5

1.11 Minor Consent Services ................................................................................1-6

1.12 Medically Indigent (MI) ...................................................................................1-6

1.13 State/County Administered Programs ............................................................1-6

1.14 Medi-Cal Benefits for Refugees .....................................................................1-6

1.15 Special Treatment Programs..........................................................................1-7

1.16 Organ Transplant Anti-Rejection Medication Program...................................1-71.16.1 Background .....................................................................................1-71.16.2 Eligibility Requirements...................................................................1-7

Identifying Eligible Beneficiaries ................................................1-8Eligibility Determination ..............................................................1-9

1.16.3 Notices of Action .............................................................................1-91.16.4 MEDS Transactions ......................................................................1-10

MEDS Alerts ............................................................................1-10

Update # 13-11 Revised: 09/30/13

Medi-Cal Handbook Table of Contents

1.17 Pickle Amendment ......................................................................................1-11

1.18 Repatriate Program [50255].........................................................................1-11

1.19 Hierarchy of Medi-Cal Programs..................................................................1-11Aged, Blind and Disabled: .......................................................1-11Families ...................................................................................1-11

2. Covered California Overview...........................................................................2-2

2.1 Affordable Care Act........................................................................................2-22.1.1 .................... Patient Protection and Affordable Care Act Overview2-22.1.2 Health Care changes since 2014....................................................2-2

Increased Access to Health Insurance ......................................2-2Affordable Coverage and Financial Support ..............................2-3Guaranteed Availability of Coverage .........................................2-3Young Adult Coverage ...............................................................2-3Preventive Care .........................................................................2-3Essential Health Benefits ...........................................................2-3Health Benefit Standard .............................................................2-3No Lifetime or Annual Limits ......................................................2-4Consumer Assistance Program .................................................2-4Penalties for No Coverage .........................................................2-4Business Healthcare Requirements ..........................................2-4Rate Increase Rules ..................................................................2-4Small Business Premium Assistance ........................................2-4

2.1.3 Health Insurance Exchange............................................................2-5

2.2 Minimum Coverage Provision ........................................................................2-52.2.1 Minimum Essential Coverage (MEC)..............................................2-6

2.3 Health Insurance Fundamentals ....................................................................2-7

2.4 Types of Insurance.........................................................................................2-8Private Health Insurance ...........................................................2-8Public Health Insurance .............................................................2-8

2.4.1 Managed Care ................................................................................2-82.4.2 Non-Managed Care ........................................................................2-92.4.3 Health Maintenance Organization...................................................2-92.4.4 Preferred Provider Organization .....................................................2-92.4.5 Exclusive Provider Organization .....................................................2-9

2.5 Insurance Options through Covered CA .....................................................2-102.5.1 Provider Network Directories ........................................................2-10

HMO, PPO, and EPO Networks ..............................................2-10Customized Networks ..............................................................2-11CalHEERS Network Directory .................................................2-11

Revised: 09/30/13 Update # 13-11


2.6 Tax Filing Threshold.....................................................................................2-11

2.7 Acceptable Applications ...............................................................................2-12

2.8 Quick Sort Transfer ......................................................................................2-122.8.1 Call Process ..................................................................................2-132.8.2 Quick Sort Transfer Flow ..............................................................2-14

Quick Sort Transfer Home County Scenario ............................2-15

2.9 Coverage Enrollment Period ........................................................................2-152.9.1 Open Enrollment ...........................................................................2-152.9.2 Special Enrollment ........................................................................2-162.9.3 APTC/CSR/QHP Renewal ............................................................2-17

2.10 Coverage Available ......................................................................................2-17

2.11 Metal Tiers....................................................................................................2-18Bronze Plan .............................................................................2-18Silver Plan ................................................................................2-18Gold Plan .................................................................................2-18Platinum Plan ...........................................................................2-19Catastrophic Coverage ............................................................2-19

2.12 APTC/CSR/QHP Eligibility ...........................................................................2-21

2.13 Tax Filing Household....................................................................................2-222.13.1 Single ............................................................................................2-222.13.2 Head of Household .......................................................................2-22

Married Exception ....................................................................2-232.13.3 Married Filing Jointly .....................................................................2-232.13.4 Married Filing Separately ..............................................................2-242.13.5 Covered CA Tax Filing Household Examples ...............................2-24

2.14 Income..........................................................................................................2-262.14.1 American Indian/Alaskan Native Income.......................................2-28

2.15 Deductions ...................................................................................................2-29

2.16 Budgeting .....................................................................................................2-302.16.1 Qualified Health Plan (QHP) .........................................................2-302.16.2 Advanced Premium Tax Credit .....................................................2-302.16.3 Cost Sharing Reduction/Enhanced Silver Plan.............................2-31

2.17 Employer Sponsored Coverage ...................................................................2-32

2.18 CalHEERS....................................................................................................2-33

2.19 Access to Health Coverage Work Flow........................................................2-34



2.20 Plan Selection ..............................................................................................2-352.20.1 Health Plan Basics........................................................................2-352.20.2 Covered Services..........................................................................2-352.20.3 Premiums......................................................................................2-362.20.4 Out-of-Pocket Costs/Cost Sharing................................................2-37

2.21 Comparing Plan Choices .............................................................................2-372.21.1 Premiums vs. Out-of-Pocket Costs ...............................................2-382.21.2 Plan Structure ...............................................................................2-382.21.3 Doctor Selection............................................................................2-38

HMO ........................................................................................2-39PPO, EPO, and other plans .....................................................2-39

2.22 Plan Enrollment............................................................................................2-39Summary of Benefits ...............................................................2-39ID Card ....................................................................................2-39Evidence of Coverage .............................................................2-40Explanation of Benefits ............................................................2-40

2.23 Changes.......................................................................................................2-40

2.24 Disenrollment ...............................................................................................2-412.24.1 Voluntary Disenrollment ................................................................2-412.24.2 Involuntary Disenrollment .............................................................2-41

2.25 Tax Penalties ...............................................................................................2-422.25.1 Tax Penalty Formula....................................................................2-43

2.26 Covered CA Appeals Process......................................................................2-45

3. Definitions & Acronyms..................................................................................3-1

3.1 Definitions, Abbreviations and Program Terms..............................................3-13.1.1 Abbreviations [50012] .....................................................................3-13.1.2 Adequate Consideration [50013] ....................................................3-23.1.3 Adult [50014] ...................................................................................3-23.1.4 Adverse Action [50015] ...................................................................3-33.1.5 Aid Category [50017] ......................................................................3-43.1.6 Aid Code [50018] ............................................................................3-43.1.7 Appertains.......................................................................................3-43.1.8 Average Private Pay Rate [50023.5]...............................................3-43.1.9 Beneficiary [50024] .........................................................................3-43.1.10 Benefits Identification Card (BIC)....................................................3-43.1.11 Board and Care [50025.3]...............................................................3-53.1.12 Burial Insurance [50025.5] ..............................................................3-53.1.13 CalWORKs [50025.7]......................................................................3-53.1.14 Cash Grant [50026].........................................................................3-5



3.1.15 Certification—Effective Date [50028] ..............................................3-53.1.16 Certification for Medi-Cal [50029]....................................................3-63.1.17 Child [50030] ...................................................................................3-63.1.18 Child Health and Disability Prevention Program (CHDP) [50031]...3-63.1.19 Coinsurance ....................................................................................3-73.1.20 Community Spouse [50031.5] .........................................................3-73.1.21 Community Spouse Resource Allowance (CSRA) [50031.7]..........3-73.1.22 Competent [50032]..........................................................................3-73.1.23 Contiguous Property [50033] ..........................................................3-83.1.24 Continuous Period of Institutionalization [50033.5] .........................3-83.1.25 Conversion of Property [50034] ......................................................3-83.1.26 Copayment ......................................................................................3-83.1.27 County Cash-Based Medi-Cal Eligibility [50035.5]..........................3-83.1.28 Deductible .......................................................................................3-93.1.29 Diligent Search................................................................................3-93.1.30 Eligibility Quality Control [50037.5] .................................................3-93.1.31 Encumbrances Of Record [50039] ..................................................3-93.1.32 Essential Person [50039.1] .............................................................3-93.1.33 Family Member [50041] ..................................................................3-93.1.34 Heirloom [50043] ...........................................................................3-103.1.35 Home [50044]................................................................................3-103.1.36 In-Home Supportive Services [50045.5] .......................................3-103.1.37 Inmate [50046] ..............................................................................3-103.1.38 Institution [50047] ..........................................................................3-113.1.39 Institution — Medical [50048] ........................................................3-113.1.40 Institution — Mental Diseases [50049]..........................................3-113.1.41 Institution — Nonmedical [50050] .................................................3-113.1.42 Institution — Private [50051] .........................................................3-113.1.43 Institution — Public [50052] ..........................................................3-113.1.44 Institution — Tuberculosis [50052.5] .............................................3-113.1.45 Institutionalized Individual [50046.4] .............................................3-123.1.46 Institutionalized Spouse [50046.5] ................................................3-123.1.47 Intraprogram Status Change [50053] ............................................3-123.1.48 Interprogram Transfer [50054] ......................................................3-123.1.49 Life Insurance [50054.5]................................................................3-123.1.50 Limited Service Status [50054.7] ..................................................3-133.1.51 Linked [50055]...............................................................................3-133.1.52 Long-Term Care (LTC) Facility [50056.5]......................................3-133.1.53 Long-Term Care (LTC) Status [50056]..........................................3-133.1.54 Marriage [50057] ...........................................................................3-143.1.55 Medi-Cal [50058] ...........................................................................3-143.1.56 Medi-Cal Family Budget Unit (MFBU) [50060] ..............................3-143.1.57 Medi-Cal Only Eligibility [50060.5].................................................3-143.1.58 Medically Indigent (MI) Person or Family [50061] .........................3-143.1.59 Medically Needy (MN) Person or Family [50062]..........................3-14



3.1.60 Medicare .......................................................................................3-153.1.61 Minimum Basic Standard of Adequate Care (MBSAC) [50063]....3-153.1.62 Minor Consent Services [50063.5] ................................................3-153.1.63 Multiple Dwelling Unit [50064].......................................................3-153.1.64 Nonrecurring Lump Sum Payment [50064.5]................................3-163.1.65 Nursing Facility [50064.7] .............................................................3-163.1.66 Nursing Facility Level of Care [50064.9] .......................................3-163.1.67 Obligate [50065]............................................................................3-163.1.68 Other Public Assistance (Other PA) Recipient [50066].................3-163.1.69 Out-of-Pocket Limit .......................................................................3-163.1.70 Overpayment [50067] ...................................................................3-163.1.71 Parent [50068] ..............................................................................3-173.1.72 Parents — Unmarried [50069] ......................................................3-173.1.73 Parent — Minor [50069.5] .............................................................3-173.1.74 Patient [50070]..............................................................................3-173.1.75 Persons Living in the Home [50071] .............................................3-173.1.76 Premium........................................................................................3-183.1.77 Prepaid Health Plan [50071.5] ......................................................3-183.1.78 Prepaid Health Plan — Comprehensive [50071.6] .......................3-193.1.79 Property — Community [50071]....................................................3-193.1.80 Property — Personal [50073]........................................................3-193.1.81 Property — Real [50074] ..............................................................3-193.1.82 Property — Separate [50075] .......................................................3-193.1.83 Property — Share of Community [50076] .....................................3-203.1.84 Provider.........................................................................................3-203.1.85 Public Assistance (PA) Recipient [50078].....................................3-203.1.86 Public Funds [50079] ....................................................................3-203.1.87 Publicly Operated Community Residence [50079.5].....................3-203.1.88 Reapplication [50081] ...................................................................3-213.1.89 Recipient [50082] ..........................................................................3-213.1.90 Redetermination [50083]...............................................................3-213.1.91 Relative [50084] ............................................................................3-213.1.92 Relative — Caretaker [50085].......................................................3-213.1.93 Repayment [50086].......................................................................3-213.1.94 Residence [50087] ........................................................................3-223.1.95 Responsible Relative [50088] .......................................................3-223.1.96 Restoration [50089].......................................................................3-223.1.97 Share-of-Cost [50090]...................................................................3-223.1.98 Share of Encumbrances [50091] ..................................................3-223.1.99 Skilled Nursing Care/Facility .........................................................3-223.1.100 State Data Exchange (SDX) [50093] ............................................3-223.1.101 Stepparent [50094] .......................................................................3-233.1.102 Supplemental Security Income/State Supplemental

Program [50095] ...........................................................................3-233.1.103 Therapeutic Wages [50095.5] ......................................................3-23



3.1.104 Third Party Liability.......................................................................3-233.1.105 Title II Disregard Person [50095.7] ..............................................3-233.1.106 Title II (Social Security Act) ..........................................................3-243.1.107 Title XVI (Social Security Act) .....................................................3-243.1.108 Title XVIII (Social Security Act) ....................................................3-243.1.109 Title XIX (Social Security Act) ......................................................3-243.1.110 Transfer of Property [50096] ........................................................3-243.1.111 U.S. Citizenship and Immigration Services (USCIS) [50045]........3-243.1.112 Verification [50097] ......................................................................3-24

4. Inquiries & Resources......................................................................................4-1

4.1 General Public Inquiries for Clients ................................................................4-14.1.1 Ability to Pay Program Determination (APD)...................................4-14.1.2 Access for Infants and Mothers (AIM).............................................4-24.1.3 “Acquired Immune Deficiency Syndrome” (AIDS) Hotline...............4-24.1.4 BabyCal...........................................................................................4-24.1.5 Breast & Cervical Cancer Treatment Program (BCCTP) ................4-34.1.6 Buy-In Problems for Medicare Parts A & B and Technical Problems for

Medicare Part D .............................................................................4-34.1.7 Child Health & Disability Prevention Program (CHDP) ...................4-34.1.8 Children’s Health Initiative (CHI) .....................................................4-44.1.9 COBRA ...........................................................................................4-44.1.10 Complaints Against Health Care Providers.....................................4-44.1.11 Consumer Information Center .........................................................4-44.1.12 Dental Services ...............................................................................4-44.1.13 Dental Treatment Options ...............................................................4-54.1.14 Doctor Services...............................................................................4-64.1.15 Electronic Data Systems (EDS) Help Desk.....................................4-64.1.16 Every Woman Counts (EWC) Program...........................................4-64.1.17 Health Care Options (HCO) ............................................................4-74.1.18 Health Insurance Billing and Coding ...............................................4-74.1.19 Health Insurance Premium Payment Program (HIPP) ....................4-84.1.20 LTC Ombudsman Program .............................................................4-84.1.21 Managed Care Ombudsman...........................................................4-84.1.22 Medical Board of California Central Complaint Unit ........................4-94.1.23 Medi-Cal Cards with Utilization Restrictions....................................4-94.1.24 Medi-Cal Fraud and Patient Abuse .................................................4-94.1.25 Medi-Cal General Information for All Aid Programs ......................4-104.1.26 Medi-Cal Managed Care Plans .....................................................4-104.1.27 Medicare .......................................................................................4-114.1.28 Medicare Part D ............................................................................4-124.1.29 Probate/Estate Recovery ..............................................................4-124.1.30 Railroad Retirement Information ...................................................4-134.1.31 Safely Surrendered Baby Hotline..................................................4-13



4.1.32 Santa Clara County Mental Health Plan (MHP)............................4-134.1.33 Senior Outreach............................................................................4-134.1.34 State Hearings and Appeals .........................................................4-144.1.35 State Programs - Disability Determination Service Division

(SP-DDSD) ...................................................................................4-144.1.36 Supplemental Security Income (SSI) and Social Security

Administration (SSA).....................................................................4-154.1.37 Third-Party Liability .......................................................................4-154.1.38 Vision Care ...................................................................................4-164.1.39 Voluntary Repayment of Benefits by Beneficiaries .......................4-16

4.2 Provider Inquiries .........................................................................................4-174.2.1 Automated Eligibility Verification System (AEVS) .........................4-174.2.2 Dental Contract Questions............................................................4-184.2.3 Drug Benefits ................................................................................4-184.2.4 Electronic Data Systems (EDS) ....................................................4-184.2.5 General Information ......................................................................4-194.2.6 Health Access Programs (HAP) Hotline........................................4-194.2.7 Non-Emergency Medical Transportation.......................................4-194.2.8 Out-of-State Authorization for Treatment ......................................4-194.2.9 Out-of-State Provider Billing .........................................................4-194.2.10 Provider Enrollment ......................................................................4-204.2.11 Treatment Authorization Requests ...............................................4-204.2.12 Vision Care ...................................................................................4-20

4.3 Contract Hospitals........................................................................................4-21

5. Applications.....................................................................................................5-1

5.1 Overview ........................................................................................................5-1

5.2 Who May File an Application for Medi-Cal [50143, 50146, 50145, 50147, 50147.1] ........................................................5-2

5.3 How to File an Application..............................................................................5-35.3.1 In-Person .......................................................................................5-35.3.2 Face-to-Face Interview ...................................................................5-4

When Required ..........................................................................5-4Failure to Keep an Appointment ................................................5-5

5.3.3 Medi-Cal Mail-In Applications .........................................................5-6Forms Not Returned ................................................................5-10

5.3.4 “Application for Cash Aid, CalFresh, and/or Medi-Cal Assistance” (SAWS 1) Requirements...............................................................5-11

5.3.5 When a SAWS 1 is Not Required .................................................5-12

5.4 Informing Requirements...............................................................................5-12



5.5 Date of Application [50151, 50181] ..............................................................5-14

5.6 Persons Who May Represent the Client ......................................................5-155.6.1 Authorized Representatives ..........................................................5-15

Who Can be Designated ..........................................................5-15Client Responsibilities ..............................................................5-15AR's Role .................................................................................5-16AR Limitations ..........................................................................5-16

5.6.2 Public Guardian.............................................................................5-175.6.3 MC 306 and Other Written Authorization .....................................5-17

Written Authorization ................................................................5-17Signature and Date ..................................................................5-19Notices of Action ......................................................................5-19Multiple ARs .............................................................................5-19Expiration of Authority ..............................................................5-19

5.6.4 Family Members............................................................................5-205.6.5 Representative Payees .................................................................5-215.6.6 Durable Powers of Attorney ..........................................................5-21

Definition ..................................................................................5-21Types of Durable Powers of Attorney ......................................5-22Conditions of Durable Powers of Attorney ...............................5-22State Policy ..............................................................................5-22Expiration of Authority ..............................................................5-23

5.7 Who Can Complete the Statement of Facts Form .......................................5-235.7.1 Who Must Complete......................................................................5-235.7.2 Applications from Non-Custodial Parents......................................5-24

5.8 Timeframes for Processing Applications ......................................................5-255.8.1 Application Processing..................................................................5-255.8.2 Immediate Need Criteria ...............................................................5-255.8.3 Beginning Date of Eligibility...........................................................5-265.8.4 Application Not Filed in the County of Residence .........................5-27

5.9 Period of Eligibility [50783] ...........................................................................5-285.9.1 Definition .......................................................................................5-285.9.2 Withdrawals/Requests for Discontinuance [50155].......................5-29

5.10 Retroactive Medi-Cal [50148, 50197, 50710]...............................................5-295.10.1 Applications...................................................................................5-295.10.2 Retroactive Medi-Cal for Mail-In Applications ...............................5-305.10.3 Eligibility Conditions ......................................................................5-315.10.4 Retroactive Medi-Cal for those Age 21 or Older ...........................5-315.10.5 Retroactive Medi-Cal Based on Disability .....................................5-31

5.11 Determining Medi-Cal Eligibility [50153].......................................................5-32



5.12 EW Follow-Up Actions .................................................................................5-34

5.13 “Application for Medi-Cal” (MC 210) [50159, 50161] ............................................................................................5-355.13.1 MC 210 and the SAWS 1..............................................................5-355.13.2 When Used ...................................................................................5-355.13.3 When the MC 210 is NOT Used ...................................................5-365.13.4 Completion of MC 210 Supplements ............................................5-365.13.5 Other Required Forms/Intake Packets..........................................5-38

5.14 “Joint Application for Children and Pregnant Women” (MC 321 HFP).........5-395.14.1 When Used ...................................................................................5-395.14.2 State Toll Free Number.................................................................5-405.14.3 MC 321 Supplements ...................................................................5-405.14.4 Other Required Forms/Intake Packets..........................................5-40

5.15 Benefits CalWIN (BCW) ...............................................................................5-41

5.16 Procedures for Phone-In Medi-Cal Applications ..........................................5-42

5.17 Procedures for Walk-In Medi-Cal Applications.............................................5-44

5.18 “Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP” (SAWS 2) ..................................................................................................................5-45

5.19 Use of the CalFresh Statement of Facts as an Application for Medi-Cal .....5-465.19.1 Overview .......................................................................................5-465.19.2 “Good News for California Families!” (SCD 90) Requirements.....5-475.19.3 Application Process ......................................................................5-475.19.4 Processing the SCD 90.................................................................5-485.19.5 When the DFA 285 A2 or FS 27 is used for Medi-Cal ..................5-485.19.6 Aligning the Medi-Cal Redetermination (RD) with the CalFresh

Recertification (RC).......................................................................5-505.19.7 Medi-Cal Eligibility Determination .................................................5-515.19.8 Informing Notices and Other Required Forms ..............................5-525.19.9 CalFresh Ineligibility/Discontinuance ............................................5-535.19.10 Required Documentation ..............................................................5-53

5.20 “Annual Eligibility Review” (AER) Form........................................................5-54

5.21 Access for Infants and Mothers (AIM) Program ...........................................5-555.21.1 AIM Denials Sent to SSA for Medi-Cal .........................................5-555.21.2 Other Required Forms ..................................................................5-555.21.3 Processing AIM Applications ........................................................5-56

5.22 Required Verifications when MC 210, MC 321 HFP, AER and AIM Application Forms Are Used ...........................................................................................5-57



5.23 Children’s Health Initiative (CHI), Intake Procedures ...................................5-585.23.1 CHI Objectives ..............................................................................5-585.23.2 How Applications are Received ....................................................5-595.23.3 Role of the Intake EW, General ....................................................5-595.23.4 Application Forms and Verifications..............................................5-605.23.5 Adding Other Family Members......................................................5-615.23.6 Property Waiver Programs ...........................................................5-61

Eligibility Criteria ......................................................................5-62Benefits ....................................................................................5-62Property Verification NOT Required ........................................5-62When Property Verification is Required ...................................5-63

5.23.7 Healthy Kids ..................................................................................5-63Eligibility Criteria ......................................................................5-63Benefits ....................................................................................5-63EW Requirements ....................................................................5-64

5.24 Applications from the Single Point of Entry (SPE)........................................5-655.24.1 “Health-e-App”...............................................................................5-65

Application Process .................................................................5-65SPE Actions .............................................................................5-66Application Date .......................................................................5-66Clerical Role .............................................................................5-66

5.24.2 SPE Applications and Forms ........................................................5-665.24.3 Application Tracking System.........................................................5-675.24.4 SPE Screening Process................................................................5-685.24.5 CIN Assignment ............................................................................5-695.24.6 Accelerated Enrollment Process (8E) ...........................................5-695.24.7 SPE Transmittal Forms .................................................................5-70

Summary Transmittal ...............................................................5-70SPE Transmittal Form ..............................................................5-70

5.24.8 Processing Applications Received from SPE................................5-75Missing Information ..................................................................5-75Required Forms .......................................................................5-76Additional Forms: .....................................................................5-76Adding Adults ...........................................................................5-76SPE File Clearance Procedures ..............................................5-77

5.25 “Express Enrollment” for Children in the National School Lunch Program (NSLP), AB 59 .............................................................................................5-785.25.1 Overview .......................................................................................5-785.25.2 Express Enrollment Definition .......................................................5-795.25.3 NSLP Application Process ...........................................................5-795.25.4 Modified NSLP Application Form ..................................................5-805.25.5 Income Verification for Express Enrollment .................................5-805.25.6 Express Enrollment Process ........................................................5-80

Activation on MEDS .................................................................5-81



Date of Application/Enrollment ................................................5-81Ineligible Children ....................................................................5-81Required Supplemental Forms/Notices ...................................5-81Information NOT Required .......................................................5-82Fair Hearing Rights ..................................................................5-83

5.25.7 Medi-Cal Eligibility Determination .................................................5-83Other Family Members Requesting Medi-Cal ..........................5-83Request for Retroactive Benefits .............................................5-84Required Actions .....................................................................5-84Dual Eligibility on MEDS ..........................................................5-85

5.26 Public Guardian Cases ................................................................................5-855.26.1 General Information ......................................................................5-855.26.2 EW Procedures.............................................................................5-865.26.3 Referrals to Public Guardian.........................................................5-875.26.4 Guardian and Conservator Fees...................................................5-87

5.27 Mental Health Sub-payee Cases .................................................................5-88

5.28 Presumptive SSI and Extended Medi-Cal....................................................5-885.28.1 Criteria for Referrals to DHCS.......................................................5-885.28.2 DHCS Responsibility.....................................................................5-895.28.3 Identification of Presumptive SSI Individuals ................................5-895.28.4 Referral Process and Required Action..........................................5-89

5.29 Foster Care Program (FCP) and Adoption Assistance Program (AAP).......5-90

5.30 Medically Indigent Adult (MIA) in LTC (53-0) ...............................................5-915.30.1 Intake ............................................................................................5-915.30.2 Continuing.....................................................................................5-92

5.31 Minor Consent..............................................................................................5-935.31.1 Retro Medi-Cal for Minor Consents...............................................5-94

5.32 San Andreas Regional Center (SARC) ........................................................5-945.32.1 Special Treatment .........................................................................5-945.32.2 MFBU/Aid Codes ..........................................................................5-955.32.3 VMC Application Process .............................................................5-95

5.33 Children’s Health Initiative (CHI) ..................................................................5-96

5.34 Tuberculosis (TB) Clinic Applications...........................................................5-98

5.35 Mental Health Applications...........................................................................5-99

5.36 Barbara Aaron Pavilion (BAP) Applications ...............................................5-100

5.37 Medassist (Argent) .....................................................................................5-1015.37.1 Procedures..................................................................................5-101



5.38 Planned Parenthood...................................................................................5-103

5.39 Therapeutic Abortions (TABs) ....................................................................5-104

5.40 Partners in AIDS Care and Education (PACE)...........................................5-105

5.41 Homeless ...................................................................................................5-106

5.42 SC 1230 Process .......................................................................................5-1075.42.1 SC 1230 Process for the Hospital ...............................................5-1075.42.2 SC 1230 Process for Clinics .......................................................5-1095.42.3 EW Process ................................................................................5-112

5.43 Renal Dialysis.............................................................................................5-113

6. Citizenship/Immigration Status .......................................................................6-1

MC 13 ........................................................................................6-1Application Consequences ........................................................6-2

6.1 Noncitizens Eligible for Full-Scope Benefits [50301]......................................6-26.1.1 Persons Eligible [50301] .................................................................6-26.1.2 Acceptable Documentation .............................................................6-3

I-551 Alien Registration Receipt Card ........................................6-3I-151 Alien Receipt Card ............................................................6-3AR-3/AR-3a Resident Cards ......................................................6-3I-137 Re-Entry Permit ................................................................6-3I-94-Arrival/Departure Record ....................................................6-3Foreign Passport Stamped ........................................................6-4I-181 B .......................................................................................6-4G-711 Individual Fee Receipt ....................................................6-5Canadian Indian Affairs Letter ...................................................6-5

6.1.3 Presumptive Eligibility .....................................................................6-5General ......................................................................................6-5Process ......................................................................................6-5

6.2 Restricted Benefits .........................................................................................6-66.2.1 Who Receives [50302] ....................................................................6-66.2.2 General Requirements ....................................................................6-76.2.3 SSN Requirement [50302] ..............................................................6-86.2.4 Emergency Care .............................................................................6-86.2.5 Pregnancy Services ........................................................................6-96.2.6 Undocumented Noncitizens and Visas ...........................................6-96.2.7 Undeclared Status...........................................................................6-96.2.8 Verification/Procedures .................................................................6-106.2.9 Immigration Reform and Control Act (IRCA Amnesty) Noncitizens .....

6-10



General Information .................................................................6-10Full Benefits .............................................................................6-11Restricted Benefits ...................................................................6-11Stuffer ......................................................................................6-12Filing Dates ..............................................................................6-12Exceptions ...............................................................................6-12Additional IRCAs ......................................................................6-13LPR Documents .......................................................................6-13Adjustment Date ......................................................................6-13Redetermination Review ..........................................................6-14Beginning Date ........................................................................6-14SAVE .......................................................................................6-14SSN Requirements [50302] .....................................................6-14

6.3 PRUCOL (Permanently Residing Under Color of Law) .............................................................................................................6-15

PRUCOL Definition ..................................................................6-16Examples of PRUCOL aliens ...................................................6-17General Provisions ..................................................................6-19Benefit Level for PRUCOL Clients ...........................................6-19

6.3.1 Categories of PRUCOL.................................................................6-196.3.2 PRUCOL for Undocumented Individuals in LTC or Receiving Renal

Dialysis..........................................................................................6-20PRUCOL Procedures for Undocumented Individuals in LTC or Renal Dialysis ..........................................................................6-21

6.3.3 Other Presumptive PRUCOL ........................................................6-236.3.4 PRUCOL Redeterminations..........................................................6-256.3.5 USCIS Responses on the G 845 ..................................................6-26

PRUCOL Approved .................................................................6-26PRUCOL Denied Aid Code 55 .................................................6-27PRUCOL for Documented Applicants ......................................6-27

6.4 U.S. Citizens ................................................................................................6-276.4.1 U.S. Born Citizens.........................................................................6-286.4.2 Citizens — Areas Outside the United States ................................6-286.4.3 Canadian Born American Indians .................................................6-286.4.4 Naturalized U.S. Citizens ..............................................................6-296.4.5 Derived or Acquired U.S. Citizenship............................................6-29

Documentation .........................................................................6-29No Documentation ...................................................................6-30Citizenship Verification for Aged Persons ................................6-30Registry Alien Status ...............................................................6-30

6.5 Verification Requirements for U.S. Citizens .................................................6-316.5.1 Background...................................................................................6-316.5.2 Verification of U.S. Citizenship and Identity ..................................6-31



U.S. Nationals ..........................................................................6-316.5.3 Frequency of Verification ..............................................................6-326.5.4 Exempt Individuals ........................................................................6-32

Presumptive Eligibility (PE) Programs .....................................6-336.5.5 Scope of Coverage .......................................................................6-33

New Applicants ........................................................................6-33Beneficiaries ............................................................................6-34

6.5.6 Electronic Birth Record Match.......................................................6-346.5.7 Social Security Number Data Match .............................................6-34

Using SSN Data Match Results ...............................................6-34Proof Already Provided ............................................................6-35Resolving Mismatches .............................................................6-35

6.5.8 Acceptable Citizenship/Identity Documents ..................................6-366.5.9 Original Documents.......................................................................6-36

Identity Documents ..................................................................6-376.5.10 Document Certification Forms.......................................................6-39

Document Certification by CAAs ..............................................6-396.5.11 Receipt of Original Documents .....................................................6-40

Citizenship and Identity Documents On File ............................6-406.5.12 Reasonable Opportunity Period ....................................................6-40

Applicants ................................................................................6-41Beneficiaries ............................................................................6-41Clients with Mismatching SSN Results ....................................6-42

6.5.13 Documents Received After Restricted Benefits are Granted ........6-426.5.14 Adding a Person to an Existing Case............................................6-426.5.15 Good Faith Effort ...........................................................................6-436.5.16 Providing Client Assistance...........................................................6-44

Requesting Birth Certificates ...................................................6-44Requesting Identity Documents ...............................................6-44

6.5.17 Single Point of Entry (SPE) Applications.......................................6-476.5.18 CalWORKs Cases.........................................................................6-476.5.19 Medi-Cal Performance Standards.................................................6-486.5.20 Processing Intake Applications .....................................................6-48

Face-to-face Interview .............................................................6-48Mail-In Applications ..................................................................6-50

6.5.21 Processing Annual Redeterminations ...........................................6-52Mail in Redeterminations - Non-MCSC ....................................6-53Adding a Person ......................................................................6-54Annual Redeterminations - MCSC ...........................................6-55Client at Outstationed Office ....................................................6-56Documents Received by Mail ..................................................6-56Adding A Person - MCSC ........................................................6-57

6.5.22 Follow Up Process for Pending Verifications ................................6-576.5.23 Questions and Answers ................................................................6-58

Automated Birth Record Matches ............................................6-58



Exempt Persons ......................................................................6-58Presumptive Eligibility: Accelerated Enrollment .......................6-61Acceptable Documents ............................................................6-61Reasonable Opportunity Period (ROP) ...................................6-63Pregnant Women .....................................................................6-64Use of Affidavits .......................................................................6-64CalWORKs Cases ...................................................................6-65

6.6 Residency/Medi-Cal Entitlement Chart ........................................................6-66

6.7 Expiration of Documents ..............................................................................6-67

6.8 Inconsistent Birthdates.................................................................................6-686.8.1 Procedure .....................................................................................6-686.8.2 Primary SAVE ...............................................................................6-686.8.3 Secondary SAVE ..........................................................................6-68

7. Residency..........................................................................................................7-1

7.1 Overview ........................................................................................................7-17.1.1 General [50320, 50320.1] ...............................................................7-17.1.2 Additional Ways to Establish Residence [50325,50327, 50329].....7-17.1.3 Who Must Provide Verification?......................................................7-37.1.4 Exception to Providing Proof of Residency.....................................7-37.1.5 When Required ...............................................................................7-37.1.6 CalWORKs to Medi-Cal Only ..........................................................7-37.1.7 Ineligibility .......................................................................................7-4

7.2 Establishing California Residency Requirements ..........................................7-4

7.3 Verification of Residency................................................................................7-57.3.1 “Specified Documents”....................................................................7-57.3.2 Other Evidence of Residency .........................................................7-67.3.3 Rent Receipt From a Relative .........................................................7-87.3.4 Free Housing ..................................................................................7-87.3.5 Unmarried Parents ..........................................................................7-87.3.6 Migrant Workers..............................................................................7-97.3.7 Homeless Persons........................................................................7-107.3.8 Foreign Students and Others With Non-Immigrant Visas .............7-107.3.9 Holders of Border Crossing Cards and Temporary Visas .............7-117.3.10 Entry to Seek Medical Care ..........................................................7-127.3.11 Case Documentation ....................................................................7-127.3.12 Unacceptable Evidence ................................................................7-13

7.4 Principal Residence .....................................................................................7-13

7.5 Public Assistance/Government Benefits ......................................................7-14



7.6 Discrepancies/Evidence to the Contrary ......................................................7-15

7.7 Temporary Absence .....................................................................................7-167.7.1 Definition [50321] ..........................................................................7-167.7.2 Temporary Absence, More Than 60 Days [50323] .......................7-177.7.3 EW Actions....................................................................................7-17

7.8 Student .........................................................................................................7-177.8.1 Individuals Who Come to California to Attend School...................7-187.8.2 California Residents Attending School in Another State ...............7-197.8.3 Parents of Out-of-State Students ..................................................7-19

8. Verifications .....................................................................................................8-1

8.1 Responsibility of Obtaining Verification [50167, 50168, 50169, 50171, 50172] ........................................................................8-18.1.1 Who.................................................................................................8-18.1.2 Lacking Verification .........................................................................8-18.1.3 Electronic Verifications....................................................................8-28.1.4 Mandatory Verifications...................................................................8-2

8.2 Face to Face Interview [50157, 50189] ..........................................................8-38.2.1 When Required ...............................................................................8-38.2.2 Documentation Required ................................................................8-3

8.3 Rights and Responsibilities [50157] ...............................................................8-38.3.1 When Required ...............................................................................8-38.3.2 Documentation Required ................................................................8-4

8.4 Timeliness of Application Process [50177(a)] ................................................8-48.4.1 When Required ...............................................................................8-48.4.2 Documentation Required ................................................................8-4

8.5 Social Security Numbers [50168] ...................................................................8-58.5.1 When Required ...............................................................................8-58.5.2 Documentation Required ................................................................8-5

8.6 Citizenship/Alien Status/Residence [50169, 50301, 50302]...........................8-68.6.1 Citizenship.......................................................................................8-6

When Required ..........................................................................8-6Verification Required ..................................................................8-6

8.6.2 Alien Status [50167 (a) (3), 50301.1, 50301.2, 50301.6, MEPM Article 7] ...................................................................................................8-12

When Required ........................................................................8-12Verification Required ................................................................8-13Systematic Verification of Entitlements (SAVE) .......................8-13

8.6.3 MC 13............................................................................................8-13



When Required ........................................................................8-138.6.4 California Residency [50167 and 50320.1] ...................................8-13

When Required ........................................................................8-14Verification Required ...............................................................8-14

8.7 Identity [50167 (a), (6)] .................................................................................8-168.7.1 When Required .............................................................................8-168.7.2 Verification Required.....................................................................8-17

8.8 Blindness and Disability [50167 (a) (1), MEPM Article 22] .........................................................................................8-188.8.1 When Required .............................................................................8-188.8.2 Documentation Required ..............................................................8-18

8.9 Incapacity [50167(a)(2), 50211] ...................................................................8-198.9.1 When Required .............................................................................8-198.9.2 Verification Required.....................................................................8-19

8.10 SGA Disability [50167, MEPM Article 22] ....................................................8-208.10.1 When Required .............................................................................8-208.10.2 Documentation Required ..............................................................8-20

8.11 Legal Responsibility for Child Applying Alone [50167 (a)(4)] .......................8-218.11.1 When Required .............................................................................8-218.11.2 Verification Required.....................................................................8-21

8.12 Need for Minor Consent Services [50147.1(a)]............................................8-218.12.1 When Required .............................................................................8-218.12.2 Documentation Required ..............................................................8-21

8.13 Medicare Eligibility[50168] ...........................................................................8-228.13.1 When Required .............................................................................8-228.13.2 Verification Required.....................................................................8-22

8.14 Health Care Benefits [50167] .......................................................................8-228.14.1 When Required .............................................................................8-228.14.2 Verification Required.....................................................................8-23

8.15 Income [50167(a)(7), 50507, 50518, 50186, MEPM Article 10 and 15] .............................................................................8-238.15.1 When Required .............................................................................8-238.15.2 Verification Required.....................................................................8-23

Earned Income ........................................................................8-23Self Employment ......................................................................8-24Use of Tax Return to Verify Income .........................................8-25Unconditionally Available Income ............................................8-25Income-In-Kind ........................................................................8-26Fluctuating Income ..................................................................8-26



Tip Income ...............................................................................8-26Temporary Workers Compensation .........................................8-26Veteran’s Benefits or Aid and Attendance Payments ..............8-26Interest and Dividend Income ..................................................8-27Child Support Spousal Support ................................................8-27Educational Grants and Loans .................................................8-27Net Income from Property ........................................................8-27Income Deductions ..................................................................8-27

8.16 Property [50167]...........................................................................................8-288.16.1 When Required .............................................................................8-288.16.2 Verification Required.....................................................................8-28

Market value of real property other than home ........................8-28Value of Stocks, Bonds, and Mutual Funds .............................8-29U.S. Savings Bonds .................................................................8-29Deeds of Trusts, Mortgages and Promissory Notes. ...............8-29Value of Nonexempt Vehicles. .................................................8-29Nonexempt Insurance Policies ................................................8-30Nonexempt jewelry (NMV over $100 each piece) ....................8-30Burial Trusts or Pre-Paid Burial Contract .................................8-30Nonexempt Property Held in Trust ...........................................8-30Value of Oil Leases ..................................................................8-30

8.17 Pregnancy [50167(a)(8)] ..............................................................................8-318.17.1 When Required .............................................................................8-318.17.2 Verification Required.....................................................................8-31

Self Declaration of Pregnancy .................................................8-32

8.18 Verifications Required Within 60 Days of Approval [50168].........................8-338.18.1 Social Security Number (SSN)......................................................8-338.18.2 Social Security Number Issuance .................................................8-338.18.3 Social Security Number Has Been Lost ........................................8-348.18.4 More Than One Social Security Number.......................................8-34

8.19 Verification of Railroad Disability..................................................................8-348.19.1 Intake ............................................................................................8-358.19.2 Continuing .....................................................................................8-358.19.3 EW Actions—Intake and Continuing .............................................8-35

Total Disability ..........................................................................8-36Occupational Disability .............................................................8-36DDSD Determination ...............................................................8-36

8.20 Verification Requirements for Retroactive Medi-Cal [50148 and 50197] .....8-368.20.1 Ex Parte Reviews [SB 87] .............................................................8-37

8.21 Additional Verification Requirements [50169] ..............................................8-378.21.1 When Required .............................................................................8-37



8.21.2 Verification Required.....................................................................8-37

9. Budgeting..........................................................................................................9-1

9.1 How to Budget Income...................................................................................9-19.1.1 Actual Income [50517] ....................................................................9-19.1.2 Treatment of Apportioned Income [50517] .....................................9-1

Earned Income Received in More Than Eight but Less Than Twelve Months ...........................................................................9-1Income Received Other Than Monthly or Semi-Monthly ...........9-1Self Employment Income ...........................................................9-2Loans .........................................................................................9-2Interest Income ..........................................................................9-2

9.1.3 Apportionment of Income Exemptions and Deductions [50517.1] ..9-39.1.4 Fluctuating Income [50518].............................................................9-39.1.5 CalWIN............................................................................................9-49.1.6 Documentation Requirements ........................................................9-5

9.2 Use of Medical Budget Worksheets ...............................................................9-5

9.3 Completion of Medical Budget Worksheets ...................................................9-59.3.1 Column I of MC 176M .....................................................................9-59.3.2 Column II of MC 176M ....................................................................9-69.3.3 Column III of MC 176M ...................................................................9-6

9.4 Use of MC 176W, Allocation/Special Deduction Worksheet-A ......................9-79.4.1 MC 176W-Allocation/Special Deduction Worksheet-A....................9-7

Part I. Children with Separate Income or Property Excluded from the MFBU ...........................................................9-7Part II. SSI/SSP or IHSS Recipient(s) in Family - Income Available/Allocated ........................................................9-8Part IV: AFDC-MN/MI Earned Income Deductions ....................9-8Part V. ........................................................................................9-8Part VI. Aged, Blind, and Disabled (ABD) Income Deductions ..9-8

10. Ex Parte Process ............................................................................................10-1

10.1 Background ..................................................................................................10-1MC 219 ....................................................................................10-2MC 13 ......................................................................................10-2

10.2 Overview ......................................................................................................10-2Step 1: Ex Parte Review ..........................................................10-2Step 2: Direct Contact ..............................................................10-3Step 3: “Medi-Cal Request for Information” (MC 355) .............10-3

10.3 Transfer to Section 1931(b) Medi-Cal ..........................................................10-3



Incomplete Income Reports .....................................................10-4

10.4 Ex Parte Review Process.............................................................................10-410.4.1 Ex Parte Review Required ............................................................10-410.4.2 No Ex Parte Review Required ......................................................10-510.4.3 Information Sources ......................................................................10-5

10.5 Direct Contact to Request Additional Information ........................................10-5

10.6 Medi-Cal Request for Information (MC 355) ................................................10-6

10.7 Time Frames for Redetermination................................................................10-6

10.8 Clients Alleging Disability .............................................................................10-8

10.9 Exhausting all Avenues of Eligibility .............................................................10-9

10.10 Eligibility Determination Procedures...........................................................10-10

10.11 RD Due Date ..............................................................................................10-11

10.12 CalWORKs Denials ....................................................................................10-12

10.13 Evaluation Chart.........................................................................................10-12

11. Redeterminations ...........................................................................................11-5

11.1 MC RD for Pre-Affordable Care Act (ACA) Recipients.................................11-5

11.2 Frequency & Timeliness [50189]..................................................................11-611.2.1 Due Date .......................................................................................11-6

MC RD Due Date When Applicant is Eligible from the First Day of the Application Month ..............................................................11-7MC RD Due Date When Applicant is eligible for retroactive benefits 11-7MC RD Due Date When Application with Retroactive Months .11-8MC RD Due Date When Applicant is not eligible in the month of application ................................................................................11-8MC RD Due Date When Family Members have different initial eligibility months .......................................................................11-9MC RD Due Date When MFBU with three children eligible for the CEC program and two different CEC periods ........................11-10

11.2.2 MC RD and CalWORKs (CW).....................................................11-11MC RD date when the CalWORKs Case is Discontinued .....11-11

11.2.3 MC RD & FFCC ..........................................................................11-1211.2.4 Resetting the Annual RD Date Based on Change in Circumstance.....

11-12Changes Reported to Other Programs ..................................11-13



Property .................................................................................11-15CalWIN Entries for Change in Circumstance RD ..................11-15

11.3 Setting the Annual RD Date for DDSD Cases ...........................................11-16

11.4 Annual Redetermination Forms .................................................................11-1811.4.1 MC RD Packets ..........................................................................11-18

MAGI MC RD Packet .............................................................11-19 ...............................................................................................11-19Mixed MC RD Packet ............................................................11-19Non-MAGI MC RD Packet .....................................................11-20LTC MC RD Packet ...............................................................11-20

11.4.2 Informational MC RD forms ........................................................11-2111.4.3 Foster Care MC RD forms ..........................................................11-22

MC 250 ..................................................................................11-22MC 250A ................................................................................11-22

11.4.4 Additional MC RD Forms ............................................................11-2211.4.5 SAWS 2 PLUS ............................................................................11-23

Example: ................................................................................11-23

11.5 CalWIN RRR ..............................................................................................11-2311.5.1 CalWIN RRR Status Definitions..................................................11-2311.5.2 Manually Printing the MC RD forms in CalWIN...........................11-2411.5.3 Reprinting MC RD forms.............................................................11-27

11.6 Mailing & Receiving Process......................................................................11-2911.6.1 Sending MC RDs without an AR.................................................11-2911.6.2 Sending MC RDs with an AR......................................................11-3011.6.3 Receiving MC RD forms .............................................................11-3111.6.4 Receiving MC RD Information Verbally.......................................11-3111.6.5 Manually logging in the MC RD ..................................................11-36

11.7 2015 MC RD process.................................................................................11-3611.7.1 Merging and Linking MC cases...................................................11-39

How to Identify if a Case Needs to be Merged ......................11-40How to Identify if a Case Needs to be Linked .......................11-41

11.7.2 Transition from pre-ACA MC to MAGI MC..................................11-43Information on other Cases and/or Programs ........................11-43Change in Circumstance RD .................................................11-44Pre-Transition Review ...........................................................11-47Review, Update & Transition Process ...................................11-48

11.7.3 Reviewing the Request for Tax Household Information (RFTHI) Forms11-49

11.7.4 Electronic Verification e-HIT to CalHEERS.................................11-54e-HIT Process ........................................................................11-55MC 216 ..................................................................................11-56

11.7.5 Non-MAGI MC RD Process ........................................................11-59



Non-MAGI Process ................................................................11-6111.7.6 Mixed Medi-Cal (Non-MAGI & MAGI) MC RDs...........................11-63

Mixed MAGI & Non-MAGI MC RD Process ...........................11-64

11.8 Rules Regarding the Annual Redetermination ...........................................11-6611.8.1 Continued Eligibility for Pre-ACA MC Children............................11-66

Exceptions Continued Eligibility for Pre-ACA MC Children ....11-6711.8.2 MAGI MC Evaluation for LTC MC ...............................................11-6711.8.3 The 90-day Cure Period..............................................................11-6811.8.4 Discontinuance of MAGI MC at RD.............................................11-69

Non-MAGI Screening Packet .................................................11-7011.8.5 Evaluation for APTC/CSR ...........................................................11-7011.8.6 MC RD for Late MC Application Approvals .................................11-71

Process ..................................................................................11-72

11.9 MC Annual RD is not returned ...................................................................11-7211.9.1 Automated Reminder Notice .......................................................11-7311.9.2 Automated Reminder Calls .........................................................11-73

Message ................................................................................11-74Missing or Invalid Telephone Numbers ..................................11-74

11.10 MC RD Rescissions ..................................................................................11-7511.10.1 Rescission Between NCO and the End of the Discontinuance Month.

11-7511.10.2 Rescissions After the End of Discontinuance Month...................11-76

11.11 Loss of Contact ..........................................................................................11-84

11.12 Face-to-face Interview Requirement [50189] .............................................11-8511.12.1 Criteria for an EW to Require A Face-to-Face Interview.............11-8511.12.2 When a Face-to-face is Required by the EW..............................11-86

11.13 CalWORKS Discontinued for Failure to Complete the Annual RD.............11-86

11.14 Deemed Eligibility for Infants......................................................................11-87

11.15 Transitional Medi-Cal .................................................................................11-88All MFBU Members are receiving TMC .................................11-88MFBU members with different TMC expiration dates ............11-88Some MFBU members are receiving TMC ............................11-88

11.16 Verification Requirements at MC RD .........................................................11-8911.16.1 Non-MAGI MC verification requirements.....................................11-8911.16.2 Income Verification for Individuals without a SSN or Taxpayer

Identification Number (TIN) .........................................................11-9011.16.3 Pending Verifications ..................................................................11-90

12. Denials/Discontinuances/Suspensions........................................................12-1



12.1 Denial or Discontinuance Due to Lack of Information, Noncooperation or Loss of Contact [50165 and 50175] .......................................................................................12-112.1.1 Balderas v. Woods ........................................................................12-112.1.2 Reasons for Denial/Discontinuance..............................................12-112.1.3 Two Contact Requirement ............................................................12-2

First Contact ............................................................................12-2Second Contact .......................................................................12-2

12.1.4 Contact..........................................................................................12-312.1.5 Mail-In Application.........................................................................12-312.1.6 Documentation Requirements ......................................................12-4

Reasonable Effort ....................................................................12-4Two Contacts ...........................................................................12-4

12.1.7 Relative Responsibility ..................................................................12-512.1.8 Subsequent Action........................................................................12-512.1.9 Good Cause..................................................................................12-6

12.2 Discontinuance Due to Death [50176] .........................................................12-612.2.1 Effective Date................................................................................12-6

12.3 Notice of Action (NOA) [50179]....................................................................12-712.3.1 When Required .............................................................................12-7

12.4 Corrective Action on Denial and Discontinuance [50182] .........................................................................................................12-712.4.1 Rescissions...................................................................................12-712.4.2 Approval/Rescission Date.............................................................12-8

12.5 Reconsideration of Denials ..........................................................................12-812.5.1 Requirement .................................................................................12-812.5.2 Decision Chart ..............................................................................12-8

12.6 Transfer Between Programs [50183] ...........................................................12-912.6.1 Requirements................................................................................12-9

12.7 Suspension of Medi-Cal Benefits for Incarcerated Juveniles.....................12-1012.7.1 Overview .....................................................................................12-1012.7.2 Program Requirements...............................................................12-1012.7.3 Process for Suspending Medi-Cal Benefits ................................12-1112.7.4 Suspension of Medi-Cal for Incarcerated Juveniles in a Medi-Cal Case

That Includes Other Family Members.........................................12-1212.7.5 Suspension of Medi-Cal for Incarcerated Juveniles in Child Only

Medi-Cal Cases ..........................................................................12-1312.7.6 Impact on Eligibility for Child Only cases ....................................12-1412.7.7 Impact on Eligibility of Other Family Members............................12-1512.7.8 Notice of Action Requirements ...................................................12-1512.7.9 Impact of SB 1147 on SB 1469 Procedures ...............................12-15



12.7.10 MEDS Screens............................................................................12-16

12.8 Medi-Cal Eligibility for Juveniles Placed Temporarily in Juvenile Detention Centers.......................................................................................................12-16

12.9 SSI/SSP Discontinuances and Denials due to Excess Income..................12-1712.9.1 Craig v. Bonta .............................................................................12-1712.9.2 SSI Denials .................................................................................12-17

Date of Application .................................................................12-1712.9.3 Eligibility Requirements...............................................................12-1812.9.4 Redeterminations ........................................................................12-1812.9.5 Retroactive Benefits ....................................................................12-1912.9.6 Continuing ...................................................................................12-1912.9.7 Documentation ............................................................................12-1912.9.8 Forms ..........................................................................................12-20

13. Change Reporting and Notices of Action.....................................................13-1

13.1 Status Reports..............................................................................................13-113.1.1 Background ...................................................................................13-113.1.2 Midyear Status Report Requirement ............................................13-113.1.3 Exempt Beneficiaries ....................................................................13-1

Rules Applying to Exempt/Non-Exempt Beneficiaries .............13-2Rules Applying to Pregnant Women ........................................13-3

13.1.4 Midyear Status Report (MC 176 S) Form......................................13-313.1.5 MSR Reporting Period ..................................................................13-413.1.6 CalWORKs Case Transitioning to Medi-Cal Only .........................13-513.1.7 MSR Processing ...........................................................................13-613.1.8 Verification Not Required ..............................................................13-613.1.9 Complete MSR Received..............................................................13-613.1.10 Incomplete MSR Received............................................................13-713.1.11 MSR Received After Discontinuance Date....................................13-813.1.12 Incomplete MSR and CEC/DE ......................................................13-813.1.13 Good Cause ..................................................................................13-9

Good Cause Reasons ..............................................................13-9Good Cause Established .........................................................13-9Timeframes ..............................................................................13-9

13.1.14 Whereabouts Unknown...............................................................13-1013.1.15 MSR Processing Guidelines: ......................................................13-1013.1.16 Adding a Person..........................................................................13-1113.1.17 Intercounty Transfers (ICT) .........................................................13-1113.1.18 CalWORKs Application Denied in MSR Due Month....................13-1213.1.19 MEDS Termination Codes for MSR ............................................13-1213.1.20 MSR Examples ...........................................................................13-13

13.2 Ten Day Reporting Requirement................................................................13-18



13.2.1 Intake Requirements...................................................................13-1813.2.2 Continuing Requirements ...........................................................13-1813.2.3 Medi-Cal Contact Update (MC 354) Form ..................................13-19

Background ............................................................................13-19MC 354 ..................................................................................13-19Signature Not Required .........................................................13-19

13.3 Notices of Action [50179, EAS 22-001.16, 22-022.4, MEPM 4U] ..............13-2013.3.1 When to Send a Notice of Action ................................................13-2013.3.2 Timely Notice of Action [50183, 50179] ......................................13-2013.3.3 Exceptions to a Timely Notice of Action [EAS 22-022.2] ............13-2113.3.4 Adequate Notice of Action [50179, EAS 22-001.1, &.2]..............13-2213.3.5 Other Notice of Action Requirements .........................................13-23

Long Term Care (LTC) Medi-Cal NOAs ................................13-2313.3.6 Elimination of Multiple or Conflicting NOAs.................................13-2413.3.7 Hierarchy of Medi-Cal Programs.................................................13-25

Aged, Blind and Disabled: .....................................................13-25Families .................................................................................13-25

13.3.8 When Multiple NOAs May Be Necessary....................................13-2513.3.9 “Conditional” Notices [50179(f)] ..................................................13-2713.3.10 NOAs and Authorized Representatives ......................................13-27

14. Health Care Options (HCO)/Managed Care ..................................................14-1

14.1 Fee-For-Service ...........................................................................................14-1

14.2 Medi-Cal Managed Care Health Plans.........................................................14-114.2.1 Comprehensive Managed Care Goals..........................................14-114.2.2 Membership Services ...................................................................14-2

14.3 Overview of the Managed Care Two-Plan Model ........................................14-214.3.1 Mandatory Enrollment ...................................................................14-314.3.2 Voluntary Aid Codes .....................................................................14-314.3.3 Exemptions from Mandatory Enrollment/Voluntary Enrollment.....14-414.3.4 Health Care Options Enrollment Contractor-Maximus..................14-5

Enrollment/Disenrollment Function ..........................................14-5Health Care Options Flyer .......................................................14-5Health Care Option Presentations ...........................................14-5

14.3.5 EW Role in the Managed Care Enrollment Process .....................14-6HCO Referrals .........................................................................14-6

14.3.6 HCO Referral Process ..................................................................14-7HCO Referral Form ..................................................................14-7

14.3.7 Enrollment Information Packet ......................................................14-8Choosing a Primary Care Provider (PCP) ...............................14-8

14.3.8 Automatic Default Into a Managed Care Plan...............................14-814.3.9 Disenrollment ................................................................................14-9



14.3.10 Two-Plan Model Identification Cards.............................................14-914.3.11 Coding Other Health Coverage with a Mandatory

Managed Care Plan and No Other Coverage .............................14-10HCP Information on MEDS ....................................................14-10

14.3.12 Cost of Care in Managed Care Plans .........................................14-1014.3.13 Managed Care Plans and Health Care Options Contact Information

and Verbal Client Contact Information Update [W&I 14005.36] ..14-11Consent ..................................................................................14-11No Consent ............................................................................14-11

14.4 Managed Care for Mental Health Services ................................................14-1214.4.1 Overview .....................................................................................14-1214.4.2 Santa Clara County’s Mental Health Plan (MHP)........................14-1214.4.3 Automatic Enrollment in the Plan ................................................14-1214.4.4 Mental Health Services ...............................................................14-13

14.5 Exemption Process for Pregnant Women That Move From Aid Code 44 to 3N During the Last Trimester...........................................................................14-1414.5.1 Informing Requirements..............................................................14-1414.5.2 Ad Hoc Listing .............................................................................14-15

15. Intercounty Transfer (ICT)..............................................................................15-1

15.1 General Requirements [50136-50138, 50185] .............................................15-115.1.1 Definitions .....................................................................................15-115.1.2 ICT Application Requirements ......................................................15-115.1.3 Continuation of Medi-Cal Benefits.................................................15-215.1.4 Redetermination of Medi-Cal Eligibility..........................................15-215.1.5 Temporary vs. Permanent Change of County Residence.............15-215.1.6 ICT Time Frames ..........................................................................15-315.1.7 Discontinuance Date .....................................................................15-315.1.8 Completion of an ICT ....................................................................15-415.1.9 Only Part of Family Moved............................................................15-415.1.10 Request for Retroactive Medi-Cal .................................................15-415.1.11 Craig v. Bonta ...............................................................................15-515.1.12 In-Home Supportive Services (IHSS)............................................15-515.1.13 Exceptions.....................................................................................15-515.1.14 CalWORKs ICT Discontinued Cases ............................................15-615.1.15 ICT Problems/Issues.....................................................................15-7

15.2 Managed Care Informing..............................................................................15-715.2.1 Managed Care Transition During ICT ...........................................15-815.2.2 Managed Care and Temporary County Change ...........................15-9

15.3 Recipient Responsibility .............................................................................15-1015.3.1 Client Contacts the Sending County and/or Requests Discontinuance



of Medi-Cal Benefits....................................................................15-1015.3.2 Client Applies in the Receiving County While the Case is Active in the

Sending County ..........................................................................15-1015.3.3 Client Requests Medi-Cal After Case Has Been Discontinued Due to

Loss of Contact ...........................................................................15-11

15.4 Client Reports Other Changes ...................................................................15-12

15.5 Annual Redetermination (RD) ....................................................................15-14

15.6 Midyear Status Report (MSR) ....................................................................15-16

15.7 Initiating an Intercounty Transfer................................................................15-18

15.8 Processing an ICT from the Sending County.............................................15-1915.8.1 Incoming ICT...............................................................................15-1915.8.2 Client Applies at District Office....................................................15-1915.8.3 Processing an Incoming ICT.......................................................15-19

15.9 Multiple Transfers.......................................................................................15-21

15.10 County of Responsibility [50135]................................................................15-2215.10.1 Courtesy Applications .................................................................15-2315.10.2 Person Maintains a Home...........................................................15-2415.10.3 Homeless Persons......................................................................15-2415.10.4 Person with a Guardian ..............................................................15-2515.10.5 Persons Under 21 Years of Age Not living at Home...................15-2515.10.6 Deceased Individual....................................................................15-2615.10.7 Out of Home Placement..............................................................15-2715.10.8 Pending SP-DDSD Disability Determination...............................15-28

16. MAGI MC Tax Household...............................................................................16-1

17. MAGI MC Income............................................................................................17-1

17.1 Self-Employment Income .............................................................................17-1

17.2 Fluctuating Income.......................................................................................17-1

17.3 Entering Reported Income ...........................................................................17-2Single Streamline Application ..................................................17-2

17.3.1 CalWIN Income Entries.................................................................17-3PAI entries in CalWIN ..............................................................17-3

17.4 CalWIN Income and Deduction Types .........................................................17-417.4.1 Income Types ...............................................................................17-417.4.2 Deductions and Expenses ..........................................................17-21



17.5 CalWIN Income & Expenses NOT Mapped to CalHEERS.........................17-2517.5.1 Income ........................................................................................17-2517.5.2 Expenses ....................................................................................17-31

18. eHIT..................................................................................................................18-1

19. Transition (MAGI/Non-MAGI/APTC) ..............................................................19-1

20. External Referral .............................................................................................20-1

20.1 Identifying and Registering a CalHEERS Application ..................................20-120.1.1 CalHEERS application with closed case in CalWIN......................20-820.1.2 CalHEERS application with pending Medi-Cal CalWIN application .....

20-2520.1.3 CalHEERS application with active CalWIN case (not Medi-Cal) - Add

a Program ...................................................................................20-2820.1.4 CalHEERS application with active Medi-Cal in CalWIN..............20-31

20.2 Processing a CalHEERS application received through the External Referral Subsystem in CalWIN ................................................................................20-34

21. Reserved for Future Use................................................................................21-1



24. Non-MAGI MC MFBU ......................................................................................24-1

24.1 Definitions.....................................................................................................24-124.1.1 Definition of an Adult [50014] ........................................................24-124.1.2 Definition of a Child [50030, 50351] ..............................................24-124.1.3 Definition of Responsible Relatives [50351]..................................24-2

24.2 Tax Dependency Requirements ..................................................................24-324.2.1 Tax Dependency Requirements [50351, 50373]...........................24-324.2.2 Persons 18-21 Years of Age [50351, 50373, 50379] ....................24-4

Persons 18-21 Years of Age Living at Home ...........................24-4Persons 18-21 Years of Age Living Away from Home .............24-5Parent Lives in California .........................................................24-5Parent Lives Out of California ..................................................24-6

24.2.3 Persons Under 18 Years of Age [50373] ......................................24-6Persons Under 18 Years of Age Living at Home .....................24-6Persons Under 18 Years of Age Living Away from Home .......24-6

24.3 Charts...........................................................................................................24-7



24.3.1 Parental Responsibility Chart........................................................24-7Unmarried Persons Under 21 Living at Home/ Away From Home ....................................................................24-7

24.3.2 Parental Responsibility Chart........................................................24-9Married, Divorced or Separated Persons Under 21 Living at Home/Away from Home ...........................................................24-9

24.4 MFBU Determinations................................................................................24-1024.4.1 MFBU [50060] .............................................................................24-1024.4.2 Family Member [50041] ..............................................................24-1024.4.3 Child [50030] ...............................................................................24-1024.4.4 Caretaker Relative [50085, 50351] .............................................24-1124.4.5 Responsible Relative [50351, 50377] .........................................24-11

24.5 MFBU Determinations: General Policy ......................................................24-1224.5.1 Sneede Requirements for MFBU Determinations.......................24-1224.5.2 Additional Rules for MFBU Determinations.................................24-1324.5.3 Common-Law Marriage ..............................................................24-14

Basic Requirements For A Common-Law Marriage ..............24-1424.5.4 Registered Domestic Partners and Same Sex Spouses.............24-14

Background ............................................................................24-14Definition of a Registered Domestic Partnership ...................24-15Eligibility for Medi-Cal ............................................................24-16

24.6 Caretaker Relative Rules and Requirements [50084]................................24-1824.6.1 Rules...........................................................................................24-1824.6.2 Relationship to Child [50084] ......................................................24-1924.6.3 Biological Relatives.....................................................................24-1924.6.4 Step Relatives.............................................................................24-1924.6.5 Spouses of Relatives ..................................................................24-1924.6.6 Adoptive Relatives ......................................................................24-2024.6.7 Relinquishment ...........................................................................24-20

24.7 Joint Custody Rules ..................................................................................24-2024.7.1 Alternating Arrangements (Joint Custody) [50374, 50213] .........24-2124.7.2 Equal Amount of Time with Each Parent ....................................24-2124.7.3 Equal Responsibility....................................................................24-2124.7.4 Alternating Periods of One Month or More .................................24-22

24.8 How to Establish an MFBU [50373- 50379] ...............................................24-22

24.9 No Family Member in LTC or Board and Care [50371]..............................24-2324.9.1 Determine Family Composition [50373] ......................................24-2324.9.2 MFBU Composition [50373] ........................................................24-2324.9.3 Ineligible Members [50379, 50657] .............................................24-25

Ineligible members of an MFBU include: ...............................24-25The following applies to ineligible members of an MFBU: .....24-27



24.9.4 Excluded Members [50381] ........................................................24-28Who are Excluded Members ..................................................24-28Rules Applied to Excluded Members .....................................24-28Adding Excluded Persons to the MFBU .................................24-29

24.9.5 Excluded Child Statement (Medi-Cal), MC 239 SN-3 .................24-2924.9.6 Ineligible vs. Excluded.................................................................24-29

Rules ......................................................................................24-2924.9.7 Unmarried Pregnant Women ......................................................24-30

Requirements .........................................................................24-3024.9.8 MFBU determination when child lives at home ...........................24-3024.9.9 MFBU Determinations when an Unmarried Minor Parent

Lives in the Home of Senior Parent(s) ........................................24-31MFBU Rules for Unmarried Pregnant Minor ..........................24-31Unmarried Minor Parent’s Child(ren) ...................................24-32Unmarried minor parents, their child and minor mother’s parents ..........................................................24-32Minor's Property .....................................................................24-32Minor's Income .......................................................................24-33Income In-Kind to Minor .........................................................24-33MFBU Chart— Married or Unmarried Minor Parent(s) Living at Home ...................................................................................24-33

24.9.10 MFBU Determination When a Married Minor Child (Parent or not) Lives in the Home of Senior Parent(s) ................24-34

MFBU Chart—Married Minor Child Living With Parents ........24-3424.9.11 MFBU Determination When a Minor, Living Away

from Home, Is Claimed as Tax Dependent .................................24-35The following applies when a parent lives in California: ........24-35The following applies when a parent lives out of California. ..24-35Determining Maintenance Need Level ...................................24-35

24.9.12 Minor Consent Services [50147, 50351, 50373] .........................24-3724.9.13 Children in Foster Care or Relinquished for Adoption.................24-37

Definition of a child in foster care: ..........................................24-37Children in foster care: ...........................................................24-37Definition of a child relinquished for adoption: .......................24-37A Child(ren) relinquished for adoption: ..................................24-37MFBU Chart — Foster Care/ Relinquished for Adoption .......24-38

24.9.14 MFBU Limitations When Families are AFDC-MN Linked [50211, 50213] ............................................................................24-38

MFBU Chart — Families with Absent or Deceased Parent Deprivation ..........24-39

24.10 Stepparents ...............................................................................................24-4024.10.1 Definitions [50094, 50375] ..........................................................24-4024.10.2 Establishing the Stepparent MFBU [50375] ................................24-4124.10.3 Stepparent Budget Computation and MC 176 W.1.....................24-42

MC 176 W.1 ...........................................................................24-42



24.10.4 Stepparent Case Property Determination ...................................24-4224.10.5 Stepparent Case Income Determination.....................................24-42

Unearned Income In-Kind and stepparent case ....................24-4324.10.6 Stepparent Determination When Parent is PA............................24-43

MFBU Illustration ...................................................................24-44

24.11 Family Members in Long Term Care or Board and Care ..........................24-4424.11.1 Definitions ...................................................................................24-44

Board and Care [50025.3] .....................................................24-44Long-Term Care Status [50056] ............................................24-45Community Spouse [50031.5] ...............................................24-46Institutionalized Spouse [50046.5] .........................................24-46Continuous Period of Institutionalization [50033.5] ................24-46

24.11.2 Adults in LTC or Board and Care [50377, PROC 8-B] ................24-47LTC Person with a Community Spouse .................................24-47ABD, No Community Spouse ................................................24-47ABD Couple ...........................................................................24-48Non-ABD Persons .................................................................24-48

24.11.3 Children in LTC [50377, PROC 8-B] ...........................................24-48Blind/Disabled LTC Child .......................................................24-48Non-Blind/Disabled LTC Child ...............................................24-48Disabled Newborns ................................................................24-48Placements ............................................................................24-49

24.11.4 Medically Indigent Adults in LTC [50157, 50377, 50191, PROC 19-C] ...........................................24-49

Background ............................................................................24-49Aid Code and Benefits ...........................................................24-49MFBU Determination .............................................................24-50Adults .....................................................................................24-50Child(ren) ...............................................................................24-50EW Responsibilities ...............................................................24-50

24.11.5 Registered Domestic Partners/Same Sex Spouses in Long Term Care24-51

24.12 Adult/Child Status Chart.............................................................................24-52

25. Non-MAGI MC Income....................................................................................25-1

25.1 General/Ownership ......................................................................................25-125.1.1 General [50501] ............................................................................25-125.1.2 Ownership of Income ....................................................................25-1

Rule .........................................................................................25-1Multiple Owners .......................................................................25-2Community Property Laws .......................................................25-2Representative Payees ............................................................25-2Trusts .......................................................................................25-2



25.1.3 Budgeting ......................................................................................25-2Medicare ..................................................................................25-2Other Health Insurance Premiums ...........................................25-3

25.2 ABD-MN Person in Board and Care With No Community Spouse [50563] .25-325.2.1 Allocations.....................................................................................25-3

25.3 Unconditionally Available Income [50186]....................................................25-325.3.1 Rule...............................................................................................25-325.3.2 Types ............................................................................................25-325.3.3 PA .................................................................................................25-425.3.4 Non-Cooperation...........................................................................25-425.3.5 Exception ......................................................................................25-4

25.4 Available Income [50605] .............................................................................25-425.4.1 Rule...............................................................................................25-425.4.2 Exception ......................................................................................25-525.4.3 Owner............................................................................................25-5

25.5 Unavailable Income [50515].........................................................................25-525.5.1 Rule...............................................................................................25-525.5.2 Types ............................................................................................25-5

Contributions ............................................................................25-5Board & Care ...........................................................................25-6Advance Earnings ....................................................................25-7Overpayment Adjustments .......................................................25-7

25.6 Exempt Income ............................................................................................25-7

25.7 Property Tax Refunds [50523] .....................................................................25-7

25.8 Child/Spousal Support Disregard [50554.5] .................................................25-7

25.9 Public Assistance Grants [50525] ................................................................25-8

25.10 CalWORKs Employment Services (CWES) [50526] ....................................25-9

25.11 Social Services Payments [50527]...............................................................25-9

25.12 Needs-Based Assistance [50529, Proc 10C] ...............................................25-925.12.1 General Criteria .............................................................................25-925.12.2 Exempted by Public Law...............................................................25-925.12.3 Other Exemptions .......................................................................25-10

25.13 Federal Housing Assistance [50529]..........................................................25-10

25.14 Training Expenses [50530].........................................................................25-10

25.15 Foster Care Payments [50531] ..................................................................25-11



25.16 Adoptive Assistance Payments..................................................................25-11

25.17 Loans, Grants, Scholarships, and Fellowships [50533] .............................25-1125.17.1 Title III Loans ..............................................................................25-1125.17.2 Title IV Student Assistance [50533] ............................................25-1225.17.3 Other ...........................................................................................25-13

25.18 Victims of Violent Crimes Program[50534] ................................................25-13

25.19 Relocation Assistance [50535]...................................................................25-13

25.20 Indian Claims [50537] ................................................................................25-14

25.21 VISTA Payments [50538]...........................................................................25-15

25.22 WIA Payments [50538] ..............................................................................25-1525.22.1 Adults ..........................................................................................25-1525.22.2 Children.......................................................................................25-1525.22.3 Verification/Information ...............................................................25-16

25.23 Executive Volunteers [50540] ....................................................................25-16

25.24 Senior Citizen Volunteers [50541]..............................................................25-16

25.25 Senior Citizens Rent Assistance [50523] ...................................................25-17

25.26 EITC [50543.5] ...........................................................................................25-17

25.27 Victims of National Socialist Persecution [50536] ......................................25-17

25.28 Japanese-American and Aleutian Restitution/Reparation/Redress Payments ...25-18

25.29 Austrian Social Insurance Payments .........................................................25-1825.29.1 Description ..................................................................................25-1825.29.2 Interest ........................................................................................25-1825.29.3 Verification ..................................................................................25-18

25.30 Filipino Veterans Equity Compensation Fund ............................................25-19

25.31 Veterans' Aid and Attendance - Not In LTC ...............................................25-20

25.32 Post 9/11 GI Bill Books and Supplies Stipend ...........................................25-20

25.33 Agent Orange.............................................................................................25-20

25.34 Disaster Assistance....................................................................................25-21

25.35 Susan Walker v. Bayer Corporation Payments ..........................................25-2125.35.1 Description ..................................................................................25-21



25.36 Quilling v. Belshe Payments.......................................................................25-2125.36.1 Description ..................................................................................25-21

25.37 Compensation in Accordance with the National Defense Authorization Act of 1997 ...........................................................................................................25-22

25.38 Ricky Ray Hemophilia Relief Fund Act Payments....................................25-22

25.39 Gifts to Children With Life-Threatening Conditions ....................................25-23

25.40 Radiation Exposure Compensation Payments.........................................25-23

25.41 Compensation for Participating in Clinical Trials ........................................25-2425.41.1 Verification ..................................................................................25-24

25.42 In-Home Care Payments............................................................................25-26

25.43 IHSS Plus Waiver Payments......................................................................25-26

25.44 Interest and Dividend Income.....................................................................25-2725.44.1 Exempt ........................................................................................25-2725.44.2 Nonexempt..................................................................................25-2725.44.3 Example ......................................................................................25-27

25.45 2009 ARRA Making Work Pay Credit.........................................................25-28

25.46 Misc. Income Information ...........................................................................25-29

25.47 Income In-Kind ...........................................................................................25-2925.47.1 Definition [50509] ........................................................................25-2925.47.2 Treatment of Income In-Kind [50511]..........................................25-3025.47.3 Exceptions [50509]......................................................................25-3025.47.4 Value of Income In-Kind..............................................................25-31

25.48 Income Verification.....................................................................................25-3125.48.1 Unearned Income........................................................................25-3125.48.2 Income In Kind ............................................................................25-3225.48.3 Earned Income............................................................................25-3225.48.4 Income Deductions .....................................................................25-33

25.49 Medi-Cal “In Home Supportive Services” Cost As a Deduction from Any Income ....................................................................25-3425.49.1 Who Is Eligible for this Special IHSS Deduction? .......................25-34

25.50 Treatment of Child Support Arrearage Payments ......................................25-3425.50.1 Current Child Support Payments (Not Arrearages).....................25-3525.50.2 Delayed (Past Month) Payments Paid Timely But Received In A

Subsequent Month (Not Arrearages) ..........................................25-35Child 18 or Older ....................................................................25-36



25.50.3 Treatment of Arrearage Payments for a Child 18 or Older .........25-36

25.51 Earned Income...........................................................................................25-37

25.52 Nonexempt Earned Income .......................................................................25-3725.52.1 Temporary Worker's Compensation ...........................................25-3925.52.2 State Disability Insurance Benefits .............................................25-39

25.53 Exempt Earned Income..............................................................................25-4025.53.1 Irregular or Infrequent .................................................................25-4025.53.2 Student Exemption......................................................................25-4025.53.3 Student Exemption Definitions....................................................25-4125.53.4 Who is Eligible ............................................................................25-4125.53.5 Child Under 14 Years..................................................................25-4125.53.6 Earned Income Tax Credit ..........................................................25-41

25.54 Deductions from Earned Income................................................................25-4225.54.1 MFBUs Which Include Aged, Blind or Disabled MN

Persons [50549] ..........................................................................25-42Student Deduction [50551] ....................................................25-43“Any Income” Deduction [50551.2] ........................................25-43Court-Ordered Spousal or Child Support [50554] ..................25-44Sixty-Five Plus One-Half [50551.3] ........................................25-44Work Expenses of the Blind [50551.4] ...................................25-44Income Necessary to Achieve Self-Support [50551.5] ..........25-44Cost of In-Home Supportive Services— ABD-MN and Substantial Gainful Activity Disabled (SGA) [50551.6] ................................................................................25-45

25.54.2 AFDC-MN, MI, or Ineligible Members of the MFBU [50553] .......25-46Deduction for Work-Related Expenses (WRE) [50553.1] ......25-46Dependent Care ....................................................................25-46Spousal or Child Support .......................................................25-47

25.54.3 All MN or MI Programs [50555]...................................................25-47

25.55 Stepparent Income.....................................................................................25-4925.55.1 Income Deemed Available from the Stepparent [50559] ............25-4925.55.2 Treatment of Income: Stepparent Cases [50561] .......................25-49

25.56 Self-Employment Income ...........................................................................25-5025.56.1 Definition .....................................................................................25-5025.56.2 Indicators of Self-Employment ....................................................25-5025.56.3 Conflicting Indicators...................................................................25-5125.56.4 Contractual Arrangement ............................................................25-5225.56.5 Determination of Property and Resources [50485] .....................25-5225.56.6 Income Determination [50505] ....................................................25-5225.56.7 Business Expenses Allowed .......................................................25-54

Mandatory Expenses



(Paid for Self-Employed Person's Employees) ......................25-54Licenses .................................................................................25-54Advertising .............................................................................25-54Bonds .....................................................................................25-54Expendable Supplies .............................................................25-55Capital Assets—Business Expenses .....................................25-55Maintenance and Repairs ......................................................25-55Taxes .....................................................................................25-55Insurance ...............................................................................25-56Transportation ........................................................................25-56Legal or Professional Services ..............................................25-56Merchandise/Stock/Raw Materials .........................................25-56Rent or Lease Expenses ........................................................25-56Home-Operated Business ......................................................25-57

25.56.8 Non-allowable Business Expense...............................................25-5725.56.9 Documenting Income Determination...........................................25-5825.56.10 Net Income From Property [50515, Procedures 10G].................25-59

25.57 Unearned Income.......................................................................................25-62

25.58 Nonexempt Unearned Income [50507] ......................................................25-6225.58.1 Workers’ Compensation..............................................................25-6325.58.2 Unavailable Workers’ Compensation ..........................................25-6425.58.3 State Disability Insurance............................................................25-6425.58.4 Disability Benefits Other than State ............................................25-6425.58.5 Other Unearned Income..............................................................25-6425.58.6 Personal Property .......................................................................25-6525.58.7 Dividends ....................................................................................25-6525.58.8 Interest ........................................................................................25-6625.58.9 Royalties .....................................................................................25-6625.58.10 Public Assistance ........................................................................25-6625.58.11 Workforce Incentive Act (WIA) ....................................................25-6625.58.12 Lump Sum...................................................................................25-6625.58.13 Other ...........................................................................................25-66

25.59 Exempt Unearned Income [50542].............................................................25-6725.59.1 Irregular/Infrequent......................................................................25-6725.59.2 Interest ........................................................................................25-67

25.60 Deductions from Unearned Income............................................................25-6825.60.1 Educational Expenses [50547]....................................................25-6825.60.2 MFBUs Which Include Aged, Blind, or Disabled MN

Persons [50549] ..........................................................................25-69Support Payment from an Absent Parent [50549.1] ..............25-69“Any Income” Deduction—Unearned Income [50549.2] ........25-70Court-Ordered Spousal or Child Support [50554] ..................25-70



Income Necessary to Achieve Self-Support [50551.5] ..........25-70Cost of In-Home Supportive Services—ABD MN and Activity Disabled (SGA) Substantial Gainful Activity [50551.6] ..........25-71Guardian and Conservator Fees [50549.3] ...........................25-71

25.60.3 AFDC-MN, MI, or Ineligible Members of the MFBU [50554] .......25-7225.60.4 All MN or MI Programs [50555]...................................................25-73

Income of an MN or MI Person Used to Determine Public Assistance Eligibility of Another Family Member [50555.1] ...25-73Health Insurance Premiums [50555.2] ..................................25-73Allocation to Excluded Children [50558] ................................25-74

25.61 Veterans’ Benefits ......................................................................................25-7425.61.1 Background.................................................................................25-7425.61.2 Aid and Attendance.....................................................................25-75

Treatment of A&A Income .....................................................25-7525.61.3 Payments for Unusual Medical Expense ....................................25-75

Treatment ..............................................................................25-75Verification .............................................................................25-75

25.61.4 Definitions ...................................................................................25-76Veteran ..................................................................................25-76Veteran’s Dependent .............................................................25-76

25.61.5 Client Responsibility....................................................................25-7625.61.6 EW Responsibility .......................................................................25-7725.61.7 CW 5 Procedures........................................................................25-77

To File Or Verify A New Claim ...............................................25-77When a CW 5 Referral is Not Necessary ..............................25-78

25.61.8 Follow-Up on CW 5 Referral .......................................................25-7825.61.9 Budgeting Information.................................................................25-7925.61.10 Veterans Educational Benefits ....................................................25-79

GI Bill .....................................................................................25-80Post 9/11 GI Bill .....................................................................25-80Veterans’ Educational Assistance Program (VEAP) ..............25-81

25.62 Unemployment Insurance Benefits/Disability Insurance Benefits ..............25-8125.62.1 Client Responsibility (Unconditionally Available Income)............25-8125.62.2 Eligibility Worker Responsibility ..................................................25-8225.62.3 Budgeting Information.................................................................25-83

25.63 Retirement Survivors Disability Insurance (RSDI) .....................................25-8525.63.1 Client Responsibility (Unconditionally Available Income)............25-8625.63.2 EW Responsibility .......................................................................25-8625.63.3 General Benefit Information ........................................................25-87

25.64 Supplemental Security Income (SSI) .........................................................25-8825.64.1 Who Is Eligible for SSI ................................................................25-8825.64.2 Who Must Apply for SSI ..............................................................25-88



25.64.3 Verification of SSI........................................................................25-8825.64.4 Other Information on SSI ............................................................25-89

25.65 Annual COLAS for Government Pensions .................................................25-9025.65.1 Public Employees Retirement System (PERS) ...........................25-9025.65.2 State Teachers Retirement System (STRS) ...............................25-9025.65.3 Civil Service Annuities (CSA)......................................................25-90

26. Property ...........................................................................................................26-1

26.1 Property Limits .............................................................................................26-126.1.1 Real Property Limits ......................................................................26-1

26.2 Availability of Property [50402].....................................................................26-1

26.3 Unavailable Property [50402] .......................................................................26-126.3.1 Intent to Liquidate or Sell the Property..........................................26-2

Bona Fide Effort and Good Faith .............................................26-226.3.2 No Ownership ...............................................................................26-2

Period of Unavailability ............................................................26-326.3.3 Property owned by Native American Indians ................................26-3

Verification ...............................................................................26-4

26.4 Property to Be Considered in Determining Eligibility [50401].......................26-426.4.1 Include...........................................................................................26-4

26.5 MFBU Determination for Property for Persons in Board and Care ..............26-5

26.6 Property Co-Ownership Chart ......................................................................26-7

26.7 Property Worksheet (MC 176P) ...................................................................26-8

26.8 Conversion of Property [50407]....................................................................26-926.8.1 Definition .......................................................................................26-926.8.2 Evaluation .....................................................................................26-9

26.9 Property Spenddown [50420, 50710].........................................................26-1026.9.1 Spenddown in Month of Application ...........................................26-1026.9.2 Spenddown for Three-Month Retroactive Medi-Cal ....................26-1126.9.3 Ongoing Medi-Cal Cases ............................................................26-1126.9.4 LTC Insurance Exemption...........................................................26-12

26.10 Excess Property Applied To Medical Bills [50421; MEPM 9L] ...................26-1226.10.1 Rule.............................................................................................26-1226.10.2 When It Applies ...........................................................................26-1326.10.3 Income v Property .......................................................................26-1326.10.4 MC 174........................................................................................26-1426.10.5 Hunt v Kizer.................................................................................26-15



26.10.6 Reviewing Property Balance at Intake ........................................26-16Over Limit ..............................................................................26-16Under Limit ............................................................................26-16Procedure ..............................................................................26-16

26.11 Retroactive Spenddown of Excess Property on Medical Expenses (Principe Exemption) .................................................................................................26-1826.11.1 Overview .....................................................................................26-1826.11.2 Impact .........................................................................................26-1826.11.3 Definitions ...................................................................................26-19

Qualified Medical Expense ....................................................26-19Principe Property Exemption .................................................26-19Principe Month .......................................................................26-20

26.11.4 Principe v. Belshe........................................................................26-2026.11.5 Verification of Payments .............................................................26-2026.11.6 MC 174 .......................................................................................26-2126.11.7 3-Month Retroactive Medi-Cal ....................................................26-2226.11.8 Informing Requirement ...............................................................26-2226.11.9 Continuing Beneficiary ................................................................26-23

26.12 Transfer of Property by Persons not in LTC...............................................26-2326.12.1 Transfers by Others (Not Currently in LTC facility) .....................26-2326.12.2 General .......................................................................................26-24

26.13 Probate/Estate Recovery [MEPM 16H].....................................................26-2426.13.1 Estate Recovery Claims..............................................................26-24

Claims Included in the Estate Recovery ................................26-25Claims that are Not Included in the Estate Recovery ............26-25Notification of Client’s Death ..................................................26-25Claims that the State May Not Pursue ...................................26-26Definition of Estate .................................................................26-26DHCS Informing Notice .........................................................26-26DHCS Informing Brochure .....................................................26-26

26.13.2 Hardship Waiver .........................................................................26-27Application for Hardship Waiver ............................................26-27

26.13.3 Liens ...........................................................................................26-27Situations When Liens May Not Be Recorded .......................26-27Property Lien Referral to the State ........................................26-28Voluntary Repayments ..........................................................26-28Post-Death Claim ...................................................................26-28Monthly Payments .................................................................26-28

26.13.4 What Happens When a Medi-Cal Recipient Dies .......................26-2926.13.5 Estate Recovery Questions ........................................................26-29

26.14 Personal Property ......................................................................................26-30

26.15 Motor Vehicles, Boats, Campers, Trailers and



Mobile Homes [Procedures 9B, 50461, 50463]..........................................26-3026.15.1 Exempt ........................................................................................26-3026.15.2 Nonexempt..................................................................................26-3026.15.3 Determination of Value................................................................26-3126.15.4 Determination of Value Using DMV License Fee Rate Table .....26-31

26.16 Cash [50451] ..............................................................................................26-3226.16.1 Exempt ........................................................................................26-3226.16.2 Nonexempt..................................................................................26-3226.16.3 Verification ..................................................................................26-33

26.17 Bank or Credit Union Accounts ..................................................................26-3326.17.1 Exempt ........................................................................................26-3326.17.2 Nonexempt..................................................................................26-3326.17.3 Verification ..................................................................................26-33

26.18 Stocks, Bonds, Mutual Funds [50456]........................................................26-3426.18.1 Exempt ........................................................................................26-3426.18.2 Nonexempt..................................................................................26-3526.18.3 Verification ..................................................................................26-3526.18.4 Determination of Value................................................................26-35

26.19 Oil Leases and Mineral Rights ...................................................................26-3526.19.1 Exempt ........................................................................................26-3526.19.2 Nonexempt..................................................................................26-3526.19.3 Verification ..................................................................................26-3526.19.4 Value ...........................................................................................26-36

26.20 Savings Bonds [50457] ..............................................................................26-36

26.21 Trust Deeds, Mortgages, Notes, RAMs [PROC 9D, 9-G, 50425, 50441]...26-3626.21.1 Exempt ........................................................................................26-3626.21.2 Nonexempt..................................................................................26-37

26.22 Home Equity Conversion (HEC) Plans.......................................................26-3726.22.1 Verification ..................................................................................26-3926.22.2 Value ...........................................................................................26-39

26.23 Tax Refunds [50454] ..................................................................................26-3926.23.1 State Refunds .............................................................................26-3926.23.2 Federal Refunds..........................................................................26-4026.23.3 Verification ..................................................................................26-4026.23.4 Time Limited Changes to Tax Credits and Refunds....................26-40

26.24 2009 ARRA Making Work Pay Credit.........................................................26-41

26.25 Loans [50483].............................................................................................26-4126.25.1 Exempt ........................................................................................26-41



26.25.2 Nonexempt..................................................................................26-4226.25.3 Verification ..................................................................................26-42

26.26 Lump Sum Payments [50445, 50455, 50507]............................................26-4226.26.1 Exempt........................................................................................26-4226.26.2 Nonexempt..................................................................................26-4326.26.3 Exception ....................................................................................26-4426.26.4 Verification ..................................................................................26-44

26.27 Life Insurance [50475]................................................................................26-4426.27.1 Exempt........................................................................................26-4426.27.2 Nonexempt..................................................................................26-4526.27.3 Verification ..................................................................................26-4526.27.4 Determination of Value ...............................................................26-4526.27.5 Availability of CSV.......................................................................26-46

26.28 Burial Insurance [50476] ............................................................................26-47

26.29 Burial Plots, Vaults, Crypts and Related Items [50477] .............................26-4726.29.1 Exempt........................................................................................26-4726.29.2 Verification ..................................................................................26-4826.29.3 Nonexempt..................................................................................26-48

26.30 Burial Funds [50479] ..................................................................................26-4826.30.1 Irrevocable Burial Funds .............................................................26-48

Exempt ...................................................................................26-48Interest ...................................................................................26-49Changing the Fund ................................................................26-49

26.30.2 Revocable Burial Funds..............................................................26-49Exempt ...................................................................................26-49Interest ...................................................................................26-50Verification .............................................................................26-50Converting to New Rules .......................................................26-51

26.30.3 Commingled Burial Funds...........................................................26-51Not Allowed ............................................................................26-51Allowable ...............................................................................26-52

26.30.4 Use for Another Purpose ............................................................26-5226.30.5 Designating the CSV of Life Insurance .......................................26-53

26.31 Life Estate Interest (Personal Property) [50442] ........................................26-5326.31.1 Nonexempt/Exempt ....................................................................26-5426.31.2 Verification ..................................................................................26-5426.31.3 Determination of Value ...............................................................26-54

26.32 Business Property [50485] .........................................................................26-5426.32.1 Exempt........................................................................................26-54

Property Intended for Self-Employment .................................26-54



26.32.2 Nonexempt..................................................................................26-5526.32.3 Rules for Business Property........................................................26-5526.32.4 Period of Exemption....................................................................26-5626.32.5 Verifications.................................................................................26-56

26.33 Jewelry [50467] ..........................................................................................26-5726.33.1 Exempt ........................................................................................26-5726.33.2 Nonexempt..................................................................................26-5726.33.3 Determination of Value................................................................26-57

26.34 Veterans' Educational Assistance Plan (VEAP) .........................................26-5826.34.1 Exempt ........................................................................................26-5826.34.2 Nonexempt..................................................................................26-5826.34.3 Verification ..................................................................................26-58

26.35 Holocaust Restitution Payments ................................................................26-5826.35.1 Exempt ........................................................................................26-5926.35.2 Nonexempt..................................................................................26-5926.35.3 Verification ..................................................................................26-59

26.36 Japanese-American and Aleutian Restitution/Reparation/Redress Payments ...26-5926.36.1 Exempt ........................................................................................26-6026.36.2 Nonexempt..................................................................................26-6026.36.3 Verification ..................................................................................26-60

26.37 Cash Payments for Medical and Social Services [50455.5].......................26-6126.37.1 Definitions ...................................................................................26-61

Medical Service ......................................................................26-61Social Service ........................................................................26-61

26.37.2 Exempt ........................................................................................26-6126.37.3 Nonexempt..................................................................................26-6226.37.4 Verification ..................................................................................26-62

26.38 Pension Funds (i.e., IRAs, Keogh) [50402, 50458] ....................................26-6326.38.1 Definition .....................................................................................26-63

Pension funds ........................................................................26-63Good Faith/Bona Fide Effort ..................................................26-63

26.38.2 Exempt ........................................................................................26-6426.38.3 Nonexempt..................................................................................26-6526.38.4 Verification ..................................................................................26-65

26.39 Excess Property Due to SSI Overpayments ..............................................26-66

26.40 Miller v Woods (IHSS Payments) ...............................................................26-67

26.41 Agent Orange Payments ............................................................................26-6726.41.1 History .........................................................................................26-67



26.41.2 Exempt........................................................................................26-6726.41.3 Nonexempt..................................................................................26-6826.41.4 Verification ..................................................................................26-68

26.42 Disaster Assistance....................................................................................26-68

26.43 Replacement of Exempt Property ..............................................................26-6926.43.1 Good Cause................................................................................26-6926.43.2 Verification ..................................................................................26-70

26.44 Payments to Crime Victims ........................................................................26-70

26.45 Prop 103 Refunds ......................................................................................26-70

26.46 Senior Citizens Rent Assistance ................................................................26-70

26.47 Filipino Veterans Equity Compensation Fund ............................................26-71

26.48 Austrian Social Insurance Payments .........................................................26-7126.48.1 Description ..................................................................................26-7126.48.2 Verification ..................................................................................26-72

26.49 Relocation Assistance Payments...............................................................26-7226.49.1 Description ..................................................................................26-7226.49.2 Exempt........................................................................................26-7226.49.3 Treatment of Interest...................................................................26-7326.49.4 Effective Date..............................................................................26-73

26.50 Specialized Adaptive Equipment................................................................26-7326.50.1 Specially Equipped Motor Vehicle ..............................................26-74

26.51 Susan Walker v. Bayer Corporation Payments ..........................................26-7426.51.1 Description ..................................................................................26-7426.51.2 Exempt........................................................................................26-74

26.52 Quilling v. Belshe Payments.......................................................................26-7526.52.1 Description ..................................................................................26-7526.52.2 Exempt........................................................................................26-7526.52.3 Verification ..................................................................................26-75

26.53 Restricted Accounts for CalWORKs or Former CalWORKs Recipients ..................................................................26-7626.53.1 Background.................................................................................26-7626.53.2 Description ..................................................................................26-7626.53.3 Example ......................................................................................26-7626.53.4 Interest Payments .......................................................................26-77

26.54 California Partnership-approved LTC Insurance Policy or Certificate........26-77



26.55 National Defense Authorization Act of 1997 Payments............................26-7826.55.1 Exempt ........................................................................................26-7826.55.2 Nonexempt..................................................................................26-7826.55.3 Verification ..................................................................................26-78

26.56 Ricky Ray Hemophilia Relief Fund Act Payments....................................26-7826.56.1 Exempt ........................................................................................26-7926.56.2 Nonexempt..................................................................................26-7926.56.3 Verification ..................................................................................26-79

26.57 Gifts to Children With Life-Threatening Conditions ....................................26-7926.57.1 Exempt ........................................................................................26-7926.57.2 Nonexempt..................................................................................26-7926.57.3 Verification ..................................................................................26-80

26.58 Other Items.................................................................................................26-80

26.59 Radiation Exposure Compensation Payments...........................................26-8026.59.1 Exempt ........................................................................................26-8126.59.2 Nonexempt..................................................................................26-81

26.60 Compensation for Participating in Clinical Trials ........................................26-8126.60.1 Verification ..................................................................................26-82

26.61 IHSS Plus Waiver Payments......................................................................26-83

26.62 Individual Development Accounts (IDA).....................................................26-8426.62.1 Exempt ........................................................................................26-8426.62.2 Nonexempt..................................................................................26-8526.62.3 Verification ..................................................................................26-85

26.63 Trusts: Similar Legal Devices (SLD) ..........................................................26-85

26.64 Endowment Life Insurance Contracts (ELIC) ............................................26-85

26.65 Trusts and Annuities [Article 9J].................................................................26-86

26.66 Background ................................................................................................26-86

26.67 Overview ....................................................................................................26-87

26.68 Treatment of Trusts ....................................................................................26-87

26.69 General Definitions.....................................................................................26-8926.69.1 Annuitant .....................................................................................26-8926.69.2 Annuitized ...................................................................................26-8926.69.3 Annuity ........................................................................................26-8926.69.4 Assets .........................................................................................26-8926.69.5 Beneficiary ..................................................................................26-90



26.69.6 Cash Refund ...............................................................................26-9026.69.7 Cost of Living Increase ...............................................................26-9026.69.8 Death Benefit ..............................................................................26-9026.69.9 Established .................................................................................26-9026.69.10 Irrevocable ..................................................................................26-9126.69.11 Payment ......................................................................................26-9126.69.12 Principal/Corpus..........................................................................26-9126.69.13 Property Right .............................................................................26-9226.69.14 Revocable ...................................................................................26-9226.69.15 Similar Legal Device (SLD).........................................................26-9226.69.16 Trust ............................................................................................26-9226.69.17 Trustee........................................................................................26-9326.69.18 Trustor.........................................................................................26-9326.69.19 Trust Income ...............................................................................26-93

26.70 Identifying Characteristic of Trusts.............................................................26-9326.70.1 OBRA ‘93 Trusts .........................................................................26-9326.70.2 Medicaid Qualifying Trusts (MQTs).............................................26-9426.70.3 Other Trusts ................................................................................26-94

26.71 Trust Comparison Chart.............................................................................26-9526.71.1 Example ......................................................................................26-95

26.72 Verification .................................................................................................26-9626.72.1 Written Trusts..............................................................................26-9626.72.2 Oral Trusts ..................................................................................26-96

26.73 Exempt Income or Property Held in Trust ..................................................26-97

26.74 Transferred Asset.......................................................................................26-97

26.75 Treatment of OBRA ‘93 Trusts...................................................................26-9826.75.1 Revocable OBRA ‘93 Trusts .......................................................26-9826.75.2 Irrevocable OBRA ‘93 Trusts ......................................................26-99

Irrevocable Trust with Disbursements Allowable ...................26-99Irrevocable Trust with NO Disbursements Allowable ...........26-100

26.75.3 Undue Hardship ........................................................................26-101When Undue Hardship Applies ............................................26-101When Undue Hardship Doesn’t Apply .................................26-102

26.76 Treatment of MQT Trusts.........................................................................26-10226.76.1 Revocable MQT ........................................................................26-10226.76.2 Irrevocable MQT .......................................................................26-103

Trust principal ......................................................................26-103Trust income ........................................................................26-103

26.76.3 Undue Hardship ........................................................................26-105

26.77 Treatment of Other Trusts........................................................................26-105



26.77.1 Revocable Other Trusts ............................................................26-10626.77.2 Irrevocable Other Trusts ...........................................................26-10626.77.3 Trusts Established on or after 8/11/93 for Disabled Individuals 26-106

Individual and Pooled Trust Characteristic Table ................26-107Recovery of Costs ................................................................26-108

26.77.4 California Uniform Gift to Minors Act (CUTMA)/Uniform Gift to Minors Act (UTMA) Trusts ..............................................26-108

Treatment .............................................................................26-109

26.78 Special Needs Trust (SNT) ......................................................................26-109

26.79 Living Trusts .............................................................................................26-110

26.80 Identifying Characteristics of Annuities ....................................................26-11026.80.1 OBRA ‘93 Annuities ..................................................................26-11126.80.2 Other Annuities .........................................................................26-112

26.81 Annuity Comparison Chart .......................................................................26-113

26.82 Verification................................................................................................26-113

26.83 OBRA ‘93 Annuity (Purchased on or after 8/11/93) .................................26-11426.83.1 Properly Annuitized ...................................................................26-11426.83.2 Determining Life Expectancy ....................................................26-11426.83.3 Treatment of a Properly Annuitized Annuity..............................26-115

Income .................................................................................26-115Property ...............................................................................26-115

26.83.4 Treatment of an Annuity Not Properly Annuitized .....................26-115Deferred Annuity ..................................................................26-116When an annuity cannot be restructured .............................26-116

26.83.5 Undue Hardship ........................................................................26-118

26.84 Other Annuities.........................................................................................26-11826.84.1 Treatment of Other Annuities ....................................................26-11926.84.2 Undue Hardship ........................................................................26-119

26.85 Annuity Distribution/Treatment Chart .......................................................26-119

26.86 Annuity Examples.....................................................................................26-120Example 1: LIFE EXPECTANCY EXCEEDS PERIOD CERTAIN ..26-120Example 2: PERIOD CERTAIN EXCEEDS LIFE EXPECTANCY - UNDUE HARDSHIP .............................................................26-121Example 3: OTHER BENEFICIARY NAMED PRIOR TO START OF PAYMENTS .........................................................................26-121Example 4: SPECIFIED DEATH BENEFIT ..........................26-121Example 5: UNSPECIFIED CASH REFUND .......................26-122Example 6: OTHER BENEFICIARY NAMED AFTER PAYMENTS



HAVE STARTED .................................................................26-122Example 7: PAYMENTS MADE TO ANOTHER PERSON - SOLE SUPPORT ...........................................................................26-122Example 8: LIFE EXPECTANCY EXCEEDS PERIOD CERTAIN ..26-123

26.87 Analysis of Sample Annuities...................................................................26-12326.87.1 Properly Annuitized Payment Schedule....................................26-12326.87.2 Improperly Structured Payment Schedule ................................26-124

Level Payment Sample ........................................................26-1263% Annual Increase Sample ...............................................26-1265% Annual Increase .............................................................26-127

26.88 Life Expectancy (L.E.) Table - Males .......................................................26-129

26.89 Life Expectancy (L.E.) Table - Females ...................................................26-131

26.90 Sneede Considerations............................................................................26-132

26.91 DHCSPrincipal Residence .......................................................................26-132

26.92 Definitions [50425] ...................................................................................26-13226.92.1 Principal Residence ..................................................................26-13226.92.2 Appertains.................................................................................26-13326.92.3 Contiguous................................................................................26-133

26.93 General Rules ..........................................................................................26-133

26.94 Exemption of Principal Residence ...........................................................26-13526.94.1 Intent to Return .........................................................................26-135

Out of State ..........................................................................26-136Out-of-County Property ........................................................26-137Intent to Return is Questionable ..........................................26-137

26.94.2 Child, Spouse or Dependent Relative in Home ........................26-137Blind Child Age 21 or Older .................................................26-137Disabled Child Age 21 or Older ...........................................26-137Dependency Requirements .................................................26-138

26.94.3 Legal Obstacles to Sell .............................................................26-13826.94.4 Client Not in LTC, Property Listed for Sale ...............................26-139

26.95 Net Nonexempt Income From Principal Residence .................................26-140

26.96 Documentation .........................................................................................26-14026.96.1 “Property Supplement” (MC 210 PS) ........................................26-140

26.97 County Level Review (Bagley v Rank).....................................................26-14126.97.1 EW Actions ...............................................................................26-141

26.98 List or Lien Requirements (Non-LTC) ......................................................26-142



Lien Requirements ...............................................................26-142List Requirements ................................................................26-142

26.98.1 “List Property for Sale - Persons Not in Long-Term Care” (MC 239 X)26-143

26.98.2 Applicant's/Beneficiary's Response, Listed at FMV ..................26-14326.98.3 Listing not Provided...................................................................26-14426.98.4 Lien Procedures ........................................................................26-14426.98.5 Effective Date of Lien ................................................................26-14526.98.6 Non-Cooperation.......................................................................26-145

26.99 Reporting Responsibilities........................................................................26-146

26.100Mandatory Informing Notices ...................................................................26-146

26.101Exemption of Principal Residence Eligibility Flow Chart ..........................26-147

26.102Other Real Property (ORP) ......................................................................26-148

26.103Exemption/Unavailability of ORP [50402] ................................................26-148

26.104Definitions [50413, 50415, 50427] ...........................................................26-15026.104.1 Fair Market Value (FMV)...........................................................26-15026.104.2 Investment Property ..................................................................26-15026.104.3 Market Value .............................................................................26-151

California property ................................................................26-151Property located outside California ......................................26-151

26.104.4 Encumbrances ..........................................................................26-151Net Market Value (NMV) ......................................................26-152

26.105Determine Ownership Share and Amount to Be Utilized .........................26-152

26.106Utilization [50416].....................................................................................26-153

26.107Time Limits for Utilization .........................................................................26-154

26.108Examples of Other Real Property (ORP) Utilization.................................26-15526.108.1 Value of ORP is Within Property Limits.....................................26-15526.108.2 Value of ORP is Over Property Limits, ORP Must Be Utilized ..26-15626.108.3 Deed of Trust, Utilization Met ....................................................26-15626.108.4 Value of ORP over $6,000, Utilization Requirements Met ........26-15626.108.5 Excess ORP Over $6,000, Not Eligible .....................................26-15626.108.6 ORP Value Under $6,000, Utilization Not Met ..........................26-157

26.109Life Estate [MEPM 9A] .............................................................................26-157

26.110Definitions ................................................................................................26-158Life Estate ............................................................................26-158Life Tenant/Beneficiary ........................................................26-158Grantor/Trustor ....................................................................26-158



Remainderman ....................................................................26-158Revocable ............................................................................26-159Irrevocable ...........................................................................26-159

26.111Life Estate Interest in Real Property ........................................................26-159Principal Residence .............................................................26-159Other Real Property (ORP) ..................................................26-159Verification ...........................................................................26-159

26.112When to Evaluate.....................................................................................26-159

26.113Method of Evaluation ...............................................................................26-16026.113.1 Revocable Life Estate ...............................................................26-16026.113.2 Irrevocable/Other Life Estates ..................................................26-16126.113.3 Determination of Past Value .....................................................26-162

26.114Life Estate Value Table............................................................................26-163

26.115Property Assessments [50142.5] .............................................................26-16426.115.1 Property Assessment Application and Statement of Facts .......26-16526.115.2 Completing the Property Assessment.......................................26-166

27. DDSD ...............................................................................................................27-1

27.1 Federally Disabled Persons [50167, Proc. 22C] ..........................................27-127.1.1 Overview .......................................................................................27-127.1.2 Definition .......................................................................................27-127.1.3 Duration ........................................................................................27-227.1.4 Other Linkage ...............................................................................27-2

27.2 DDSD Referral Not Required ......................................................................27-2

27.3 Who Should Not Be Referred to DDSD .......................................................27-3

27.4 DDSD Referral Required..............................................................................27-427.4.1 MC 210 .........................................................................................27-527.4.2 Blindness .....................................................................................27-627.4.3 Client's Statement .........................................................................27-727.4.4 RSDI/SSI Pending ........................................................................27-727.4.5 Presumptive Disability...................................................................27-7

27.5 Promptness ..................................................................................................27-7

27.6 RSDI/SSI Pending........................................................................................27-8

27.7 Retro Onset Dates .......................................................................................27-9

27.8 Disability Determination Service Division (DDSD) Referral Limited by SSA Decision .......................................................................................................27-9



27.8.1 Overview .......................................................................................27-927.8.2 Conditions ...................................................................................27-1027.8.3 Screening Form...........................................................................27-1127.8.4 Completion of MC 223 or MC 223C ............................................27-1127.8.5 Informing Notice/NOAs ...............................................................27-1127.8.6 Referring Clients to Social Security.............................................27-1227.8.7 SSA Approves Disability After Originally Denying Claim.............27-1227.8.8 Discontinuance of SSA Disability Benefits - “Cessation of Disability” ..

27-13Social Security Appeal Process .............................................27-13EW Action ..............................................................................27-13

27.8.9 Discontinuance of SSI/SSP Disability Benefits - “Non-Disability Reasons” .....................................................................................27-14

27.9 Disability Determination Service Division (DDSD) Decision Chart .............27-1527.9.1 SSA/DDSD-SP Client Referral Chart ..........................................27-16

27.10 Other Linkage.............................................................................................27-17

27.11 Presumptive Eligibility (PD) ........................................................................27-17

27.12 Deceased DDSD Applicants ......................................................................27-18

27.13 Determining Substantial Gainful Activity (SGA) .........................................27-1827.13.1 Background/Definition .................................................................27-1827.13.2 When to Apply SGA Procedures.................................................27-1927.13.3 Presumptive Disability and SGA .................................................27-1927.13.4 Retroactive Medi-Cal and SGA ...................................................27-2027.13.5 SGA Does Not Apply...................................................................27-2027.13.6 Income In-Kind and SGA ............................................................27-2127.13.7 Procedures..................................................................................27-2127.13.8 Impairment-Related Work Expenses (IRWEs) ............................27-22

Conditions ..............................................................................27-22MC 272 ..................................................................................27-23MC 273 ..................................................................................27-23Budgeting IRWE ....................................................................27-23

27.13.9 Types of IRWE ............................................................................27-24Attendant Care .......................................................................27-24Transportation Costs ..............................................................27-25Medical Devices .....................................................................27-25Prosthesis ..............................................................................27-25Work-Related Equipment and Assistants ..............................27-25Residential Modifications .......................................................27-26Drugs, Medical Services, Diagnostic Procedures, and Medical Supplies ....................................................................27-26Non-Medical Appliances/Devices ..........................................27-26Other Items and Services ......................................................27-26



27.13.10 Work Subsidies ...........................................................................27-26Subsidies: ..............................................................................27-27

27.13.11 Medi-Cal Budget .........................................................................27-2727.13.12 Unsuccessful Work Attempt (UWA) ............................................27-2827.13.13 Example of an SGA Determination .............................................27-28

27.14 Disability Referral Checklist .......................................................................27-29

27.15 DDSD — Providing EW Observations .......................................................27-31

27.16 Use of MC 221 or DHS 7045 .....................................................................27-31

27.17 Guidelines for Observations.......................................................................27-3127.17.1 General .......................................................................................27-3127.17.2 Physical Mobility .........................................................................27-3227.17.3 Physical Appearance ..................................................................27-3227.17.4 Other Physical Problems ............................................................27-3227.17.5 Special Senses ...........................................................................27-3327.17.6 Mental and Emotional Status ......................................................27-33

27.18 DDSD — Disability Evaluation Forms ........................................................27-34

27.19 Forms/Documents to be Included in the DDSD Packet .............................27-3427.19.1 List of Forms ...............................................................................27-3427.19.2 List of Documents .......................................................................27-35

Medical Records ....................................................................27-35SSA Documents ....................................................................27-35Death Certificate ....................................................................27-36

27.20 “What You Should Know About Your Medi-Cal Disability Application” (MC 017)27-3627.20.1 Purpose.......................................................................................27-36

27.21 “90-Day Status Letter” (MC 179)................................................................27-3627.21.1 Purpose.......................................................................................27-36

27.22 “Authorization for Release of Information” (MC 220) ....................................................................................................27-3727.22.1 Purpose.......................................................................................27-3727.22.2 How Many? .................................................................................27-3727.22.3 Completion Requirements ..........................................................27-37

Appropriate Actions ...............................................................27-37Inappropriate Actions .............................................................27-37

27.22.4 Signature Requirements .............................................................27-37Exceptions/Special Situations ................................................27-38

27.22.5 Reminders...................................................................................27-3927.22.6 Revocation ..................................................................................27-40



27.23 “Disability Determination and Transmittal” (MC 221) ....................................................................................................27-4027.23.1 Completion Requirements...........................................................27-40

Items 1-4 and 7 ......................................................................27-40Item 2 .....................................................................................27-41Item 5 .....................................................................................27-41Item 6 .....................................................................................27-41Item 8 .....................................................................................27-41Item 9 .....................................................................................27-41Item 10 ...................................................................................27-41Items 11, 12 ...........................................................................27-42Items 13-20 ............................................................................27-42

27.24 “DDSD Pending Information Update” (MC 222) .........................................27-4227.24.1 Purpose.......................................................................................27-4227.24.2 Types of Changes to Report .......................................................27-43

27.25 “Applicant's Supplemental Statement of Facts for Medi-Cal” (MC 223) .....27-4327.25.1 Purpose.......................................................................................27-4327.25.2 Impact of Prior SSA Decision......................................................27-4327.25.3 Completion Requirements: Part I — Personal Information .........27-44

Item 1a ...................................................................................27-44Item 1b ...................................................................................27-44Item 1c ...................................................................................27-44Item 1d ...................................................................................27-44Item 1e ...................................................................................27-44Items 1f-1g .............................................................................27-44Items 2a-2b ............................................................................27-44Item 3 .....................................................................................27-45Item 4a-4b ..............................................................................27-45

27.25.4 Part II — Medical Information......................................................27-45Item 5a - 5d ............................................................................27-45Item 6 .....................................................................................27-45Items 7-8 ................................................................................27-45Item 9 .....................................................................................27-46Item 10 ...................................................................................27-46Item 11 ...................................................................................27-46Item 12 ...................................................................................27-46Item 13 ...................................................................................27-47

27.25.5 Part III — Social and Educational Information ............................27-47Item 14 ...................................................................................27-47Item 15a - 15c ........................................................................27-47Item 16 ...................................................................................27-47

27.25.6 Part IV — Work History ...............................................................27-48Item 17a - 17b ........................................................................27-48

27.25.7 Part V — Signature and Certification ..........................................27-48



27.26 “Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age of 18” (MC 223C)..................................................................................................27-4927.26.1 Purpose.......................................................................................27-4927.26.2 Impact of Prior SSA Decision......................................................27-4927.26.3 Completion Requirements: Part 1 — Personal Information ........27-49

Item A ....................................................................................27-49Item B ....................................................................................27-50Item C ....................................................................................27-50Item D ....................................................................................27-50Items E-F ...............................................................................27-50Item G ....................................................................................27-50Item H ....................................................................................27-50Item I ......................................................................................27-50

27.26.4 Part 2 — The Child’s Illnesses, Injuries, or Medical Conditions..27-51Item A ....................................................................................27-51

27.26.5 Part 3 — Social Security/SSI Information ...................................27-51Items A-D ...............................................................................27-51

27.26.6 Part 4 — Special Sources and School Information.....................27-51Item A ....................................................................................27-51Item B ....................................................................................27-51Item C ....................................................................................27-51Item D ....................................................................................27-52Item E ....................................................................................27-52Item F .....................................................................................27-52Item G ....................................................................................27-52Item H ....................................................................................27-52Item I ......................................................................................27-52

27.26.7 Part 5 — Medical Information .....................................................27-53Item A ....................................................................................27-53Item B ....................................................................................27-53

27.26.8 Part 6 — Medications..................................................................27-5427.26.9 Part 7 — Tests ............................................................................27-5427.26.10 Part 8 — Work History ................................................................27-5427.26.11 Part 9 — Remarks ......................................................................27-5427.26.12 Part 10 — Signature and Certification ........................................27-55

27.27 “SGA Worksheet” (MC 272) .......................................................................27-55

27.28 “Work Activity Report” (MC 273) ................................................................27-55

27.29 “Medi-Cal Report on Adult/Child With Allegation of HIV” (DHCS 7035 A / DHCS 7035 C) ......................................................................................................27-56

27.30 “Worker Observations - Disability” (DHCS 7045).......................................27-56

27.31 “DDSD Transmittal” (SCD 1475)................................................................27-56



27.31.1 Users of SCD 1475 .....................................................................27-5727.31.2 Online Form ................................................................................27-5727.31.3 Instructions for Completion .........................................................27-57

27.32 DDSD — EW Procedures ..........................................................................27-58

27.33 Recording DDSD Pending..........................................................................27-58

27.34 Sending the DDSD Packet .........................................................................27-59

27.35 DDSD Address/ Phone...............................................................................27-59

27.36 Delayed DDSD Referrals ...........................................................................27-6027.36.1 Background .................................................................................27-6027.36.2 Procedure....................................................................................27-6027.36.3 Packets Rejected by DDSD ........................................................27-6127.36.4 DDSD Actions When Referral is Received..................................27-6127.36.5 Reporting Changes to DDSD ......................................................27-62

27.37 DDSD Decisions.........................................................................................27-6327.37.1 Is Disabled ..................................................................................27-6427.37.2 Is Not Disabled............................................................................27-6427.37.3 No Determination ........................................................................27-6527.37.4 “No Determination” (Noncooperation by Doctor).........................27-67

27.38 DDSD Status Reports ................................................................................27-6727.38.1 Description ..................................................................................27-67

Pending List ...........................................................................27-68Closed List .............................................................................27-68

27.38.2 Basis Codes ................................................................................27-68Allowance Basis Codes (Disability Approved) .......................27-69Denial Basis Codes (Disability Denied) .................................27-69No Determination Basis Codes ..............................................27-70“Z” Codes ...............................................................................27-70

27.38.3 Monitoring Requirements ............................................................27-7027.38.4 SSPMs ........................................................................................27-7027.38.5 Follow-up Action - EW Supervisors and EWs .............................27-7127.38.6 DDSD Decision Needed..............................................................27-71

27.39 DDSD Inquiries...........................................................................................27-7127.39.1 District Office DDSD Liaison .......................................................27-7127.39.2 Medi-Cal Program Coordinator ...................................................27-72

27.40 DDSD Referral Packets..............................................................................27-7227.40.1 Full Packet ..................................................................................27-7227.40.2 Limited Packet.............................................................................27-7227.40.3 Options to Process Disability Evaluation Referral Packets .........27-73



27.41 DDSD — Special Referrals ........................................................................27-73

27.42 Limited DDSD Referral...............................................................................27-7327.42.1 Allowable Circumstances............................................................27-7327.42.2 Required Forms ..........................................................................27-74

27.43 DDSD Referral for a Retro Month ..............................................................27-7527.43.1 New Applicant .............................................................................27-7527.43.2 DDSD Pending............................................................................27-7527.43.3 After DDSD Approval ..................................................................27-75

27.44 Referral for Former SSI/SSP Recipient - Discontinued for Reasons Other than “Cessation of Disability” .............................................................................27-7627.44.1 Purpose.......................................................................................27-7627.44.2 DDSD Referral ............................................................................27-7627.44.3 DDSD Approval...........................................................................27-7727.44.4 No Decision.................................................................................27-77

27.45 Referral for Former SSI/SSP Recipient - “Cessation of Disability”.............27-7727.45.1 Purpose.......................................................................................27-7727.45.2 DDSD Referral ............................................................................27-7827.45.3 No Decision.................................................................................27-78

27.46 DDSD — Reexaminations, Redeterminations, and Reevaluations............27-79

27.47 RSDI and Disability ....................................................................................27-7927.47.1 Overview .....................................................................................27-7927.47.2 Verification Requirement.............................................................27-79

Intake .....................................................................................27-79Redetermination ....................................................................27-80

27.47.3 Follow-Up....................................................................................27-80

27.48 Determined Disability ................................................................................27-8027.48.1 Overview .....................................................................................27-8027.48.2 Types of Referrals to DDSD .......................................................27-80

27.49 Reexaminations .........................................................................................27-8127.49.1 No Federal Decision Involved .....................................................27-8127.49.2 Federal Decision Involved...........................................................27-82

Exception ...............................................................................27-8327.49.3 HIV Exception .............................................................................27-83

27.50 Redeterminations .......................................................................................27-84

27.51 Reevaluations ............................................................................................27-8527.51.1 DDSD Independent Review Claim..............................................27-8627.51.2 DDSD Adopted SSA’s Decision..................................................27-86



New Condition ........................................................................27-86Same Condition .....................................................................27-86

27.52 DDSD Referral Chart..................................................................................27-8727.52.1 Reexamination Referral Procedures ...........................................27-87

Responsibility Chart ...............................................................27-8727.52.2 Redetermination Referral Procedures.........................................27-8927.52.3 Reevaluation Referral Procedures ..............................................27-90

27.53 Failure to Cooperate...................................................................................27-91

27.54 Reexaminations on Appealed DDSD Denials ............................................27-91

27.55 DDSD — Presumptive Disability (PD)........................................................27-92PD Criteria .............................................................................27-93

27.56 Effective Date .............................................................................................27-93

27.57 3 Month Retro.............................................................................................27-94

27.58 Federal Denial ............................................................................................27-94

27.59 Presumptive Disability (PD) Categories .....................................................27-95

27.60 HIV/AIDS Policy .........................................................................................27-99

27.61 Presumptive HIV/AIDS Procedures............................................................27-99

27.62 HIV/AIDS, Adults (Presumptive Criteria Met) ...........................................27-100

27.63 HIV/AIDS, Children, Birth Through Age 17 (Presumptive Criteria Met) ...27-102

27.64 EW Grants PD..........................................................................................27-103

27.65 EW Requests PD Consideration from DDSD (For Urgent Case Requests)........27-103

27.66 Urgent Case Request...............................................................................27-10427.66.1 DDSD Criteria to Grant PD for Urgent Case Requests .............27-104

27.67 Procedures for Urgent Case Request ......................................................27-105

27.68 Examples of Situations Requiring Urgent Case Request.........................27-106

27.69 Follow-Up/Expediting Decisions...............................................................27-107

27.70 Verification Requirement ..........................................................................27-107

27.71 Presumptive Disability (PD) Checklist ......................................................27-108

27.72 .................................................................................................................27-109



28. Aged Blind and Disabled (ABD) Programs ..................................................28-1

28.1 Aged and Disabled Federal Poverty Level (A&D FPL) Program.....................................................................................28-128.1.1 Background...................................................................................28-128.1.2 Program Overview ........................................................................28-128.1.3 Eligibility Criteria ...........................................................................28-128.1.4 Referral of Blind Applicants...........................................................28-2

SP-DDSD Referral ...................................................................28-228.1.5 Application for the A&D FPL Program ..........................................28-2

Intake .......................................................................................28-2Continuing Cases ....................................................................28-2

28.1.6 Scope of Benefits and Aid Codes .................................................28-328.1.7 Eligibility Determination for Individuals and Couples ....................28-328.1.8 Eligibility For One Spouse Only ....................................................28-328.1.9 Eligibility For Couples that Fail the First Income Test ...................28-4

Second Budget ........................................................................28-4Switching Status ......................................................................28-4Procedures to Determine Eligibility for Couples Who Fail the First Test ..........................................................................................28-5Example ...................................................................................28-6January COLA .........................................................................28-7

28.1.10 MFBU Requirements ....................................................................28-728.1.11 Notices of Action (NOA) Requirements.........................................28-7

Approval of Benefits .................................................................28-7Discontinuance of Benefits ......................................................28-7

28.2 Federal Poverty Level for the Blind (FPLB) Program...................................28-828.2.1 Eligibility Criteria ...........................................................................28-828.2.2 Verification ....................................................................................28-828.2.3 Medically Needy............................................................................28-928.2.4 Notice of Action.............................................................................28-928.2.5 Examples ......................................................................................28-928.2.6 Retroactive Benefits ......................................................................28-9

29. Long Term Care (LTC)....................................................................................29-1

29.1 Definitions ....................................................................................................29-129.1.1 Common Law Marriage.................................................................29-229.1.2 Community Spouse [50031.5].......................................................29-229.1.3 Community Spouse Monthly Income Allowance (CSMIA) ............29-229.1.4 Community Spouse Resource Allowance (CSRA)[50031.7].........29-229.1.5 Competent [50032] .......................................................................29-229.1.6 Continuous Period of Institutionalization [50033.5] .......................29-329.1.7 Institution - LTC Medical Facilities ................................................29-329.1.8 Institutionalized Spouse [50046.5] ................................................29-3



29.1.9 Long Term Care Status [50056] ....................................................29-429.1.10 Minimum Monthly Maintenance Need Allowance (MMMNA) ........29-429.1.11 Nursing Facility [50064.71]............................................................29-429.1.12 Nursing Facility Level of Care [50064.9] .......................................29-529.1.13 Nursing Facility Level of Care During the Period of Ineligibility.....29-529.1.14 Registered Domestic Partners and Same Sex Marriage [Refer to

“Registered Domestic Partners (RDP) /Same Sex Spouse in Long Term Care,” page 29-23]...............................................................29-5

29.1.15 Skilled Nursing Care/Facility .........................................................29-5

29.2 Long Term Care Eligibility ............................................................................29-5A person with linkage (ABD) in a LTC medical facility: ............29-6

29.3 Institution for Mental Diseases (IMD) ...........................................................29-729.3.1 Individuals Under 21 .....................................................................29-829.3.2 Individuals Between Age 21-65.....................................................29-8

29.4 Application....................................................................................................29-929.4.1 LTC and Incompetent Persons .....................................................29-9

Determination of Competency .................................................29-9Who May Apply [50143] .........................................................29-10Who May Complete the Application [50077, 50163] ..............29-10Knowledge of Client's Circumstances ....................................29-11DHCS 7068 ............................................................................29-11Incompetent Persons Cannot Designate an AR ....................29-12

29.5 Resources ..................................................................................................29-1229.5.1 LTC Ombudsman Program .........................................................29-1229.5.2 Probate/Estate Recovery ............................................................29-1229.5.3 Managed Care Disenrollment When Entering LTC.....................29-1229.5.4 Voluntary Repayment of Benefits by Beneficiaries .....................29-13

29.6 County of Responsibility.............................................................................29-1329.6.1 Long Term Care Clients ..............................................................29-13

CalWIN System ......................................................................29-15

29.7 Redetermination .........................................................................................29-1529.7.1 MC 262........................................................................................29-15

29.8 Medicare.....................................................................................................29-1529.8.1 Medicare Buy-In ..........................................................................29-15

29.9 Notices of Action (NOA) .............................................................................29-1629.9.1 LTC Medi-Cal NOA’s...................................................................29-16

Long Term Care (LTC) Medi-Cal NOAs .................................29-1629.9.2 NOA’s and AR’s for Competent Clients.......................................29-16

29.10 Former SSI/SSP Recipient.........................................................................29-17



29.11 California Residency ..................................................................................29-17

29.12 .................................................................. Citizenship/Immigration Status29-1829.12.1 PRUCOL for Undocumented Individuals in LTC or Receiving Renal

Dialysis........................................................................................29-18Prucol Procedures for Undocumented Individuals in LTC .....29-19

29.12.2 PRUCOL Redeterminations........................................................29-2129.12.3 PRUCOL Response/Approval.....................................................29-2129.12.4 PRUCOL Denied aid code 55 .....................................................29-21

29.13 MFBU Determination [50060].....................................................................29-2229.13.1 Responsible Relative ..................................................................29-2229.13.2 Registered Domestic Partners (RDP) .........................................29-2229.13.3 Registered Domestic Partners (RDP) /Same Sex Spouse in Long

Term Care...................................................................................29-2329.13.4 Adults in LTC [50377, PROC 8-B] ..............................................29-24

Non-ABD Persons .................................................................29-2529.13.5 Children in LTC [50377, PROC 8-B] ...........................................29-2529.13.6 Medically Indigent Adults in LTC.................................................29-26

Aid code and Benefits ............................................................29-26Adults .....................................................................................29-27EW Responsibilities ...............................................................29-27

29.13.7 Medically Indigent Children in LTC .............................................29-28Children in LTC ......................................................................29-28

29.14 Treatment of MIA Residents of Skilled Nursing/Intermediate Care Facilities......29-31

Retroactive Eligibility ..............................................................29-31Medi-Cal Identification Card ..................................................29-32

29.15 Long-Term Care Admission and Discharge Procedures............................29-33

29.16 Property......................................................................................................29-3429.16.1 Do Not Include in the Property Consideration.............................29-3429.16.2 MFBU Determination for Property...............................................29-3429.16.3 Voluntary Payment Program -

Persons in Long Term Care (LTC) Facilities...............................29-3729.16.4 LTC Insurance Exemption ..........................................................29-3929.16.5 California Partnership-Approved LTC Insurance Policy or Certificate .

29-3929.16.6 Overview .....................................................................................29-3929.16.7 Policy ..........................................................................................29-3929.16.8 Qualification ................................................................................29-4029.16.9 Verification ..................................................................................29-4029.16.10 Property Exemption ....................................................................29-4129.16.11 Duration of Property Exemption..................................................29-4129.16.12 Additional Information .................................................................29-42



29.16.13 Examples ....................................................................................29-42Situation #1 ............................................................................29-42Situation #2 ............................................................................29-43Situation #3 ............................................................................29-43Situation #4 ............................................................................29-44

29.16.14 Community Property Rules for the Treatment of Property for Couples With One Spouse in LTC ............................................................29-44

29.16.15 Overlapping Property Regulations: .............................................29-45Chart - Which Property Rules Apply? ....................................29-46

29.16.16 Community Spouse/Same-Sex Spouse/RDP/RDP Resource Allowance (CSRA) [Section 50490.5] .........................................29-47

29.16.17 Definitions ...................................................................................29-4729.16.18 Calculation of the CSRA .............................................................29-48

General ..................................................................................29-48Maximum CSRA ....................................................................29-49Chart Value ............................................................................29-49Court Order ............................................................................29-49Fair Hearing ...........................................................................29-50Total Property ........................................................................29-50

29.16.19 Transfer of the CSRA to the Community Spouse/Same-Sex Spouse/RDP/RDP.......................................................................29-51

Rule ........................................................................................29-51Transfer Period ......................................................................29-51

29.16.20 Adding to the CSRA ....................................................................29-5229.16.21 Undue Hardship for Establishing CSRA......................................29-5229.16.22 Married v Separated for Purposes of Applying CSRA.................29-5329.16.23 EW Actions in Deeming CSRA....................................................29-5429.16.24 CRSA Examples .........................................................................29-54

Example 1: CSRA Includes Separate Property of Community Spouse/Same-Sex Spouse/RDP ...........................................29-54Example 2: Court Order .........................................................29-55Example 3: Undue Hardship Exists .......................................29-55

29.16.25 Transfers of Property on or After 1/1/90 [50408, 50411] ............................................................................29-56

29.16.26 Institutionalized Persons .............................................................29-5629.16.27 General .......................................................................................29-5629.16.28 Non-Disqualifying Transfers ........................................................29-57

Exempt Property ....................................................................29-57CSRA .....................................................................................29-57Other Reasons .......................................................................29-57Intent to Get Full Value ..........................................................29-57Certain Transfers to spouse/same-sex spouse/RDP or Child 29-57Principal Residence ...............................................................29-58Undue Hardship .....................................................................29-59Hospice Care .........................................................................29-59



29.16.29 Disqualifying Transfers ...............................................................29-6029.16.30 Period of Ineligibility (POI) ..........................................................29-60

General Rule ..........................................................................29-60CalWIN and MC 176 PI .........................................................29-60Average Private Pay Rate (APPR) ........................................29-62

29.16.31 Period of Ineligibility (POI) Example ...........................................29-6429.16.32 Consecutive Transfers ................................................................29-6529.16.33 MEDS Restriction Coding ...........................................................29-66

General ..................................................................................29-6629.16.34 Division of Community Property..................................................29-6729.16.35 Separate Property [50075, 50403] ..............................................29-6729.16.36 Community Property [50072, 50403] ..........................................29-6829.16.37 Automatic Division Rules ............................................................29-6829.16.38 Inter spousal Agreements ...........................................................29-70

Inter spousal Agreement Requirements ................................29-70Limitations of the Inter spousal Agreement [50408, 50409] ..29-71Filing the Inter spousal Agreement ........................................29-72Division of Community Property Documentation ...................29-72Advising Applicants/Beneficiaries ..........................................29-72

29.16.39 Principal Residence ....................................................................29-7229.16.40 Intent to Return ...........................................................................29-7229.16.41 Client in LTC, Sibling or Child Over Age 21 in Home..................29-7329.16.42 List Property for Sale - Persons in Long-Term Care” (MC 239 Y) .......

29-7429.16.43 Client in LTC with List and Lien ..................................................29-7429.16.44 List and Lien Requirements (LTC) ..............................................29-7529.16.45 Transfer of Nonexempt Principal Residence by Institutionalized

Persons.......................................................................................29-75

29.17 Income .......................................................................................................29-7629.17.1 Ownership of Income ..................................................................29-76

Background [50512] ...............................................................29-7629.17.2 Income Allocations, ABD-MN Person with LTC

Status Who Has a Community Spouse/Same-Sex Spouse/RDP [50563] ........................................................................................29-76

29.17.3 Rule.............................................................................................29-7629.17.4 Dependent Family Members.......................................................29-7729.17.5 Proof of Dependency ..................................................................29-7729.17.6 Maximum Allocation to Community Spouse/Same-Sex Spouse/RDP.

29-78Court Order ............................................................................29-78Fair Hearing ...........................................................................29-78

29.17.7 Verification of Community Spouse/Same-Sex Spouse/RDP Allocation29-79

29.17.8 Verification of Dependent: Family Member Maximum Base Allocation29-79



29.17.9 Total Allocation............................................................................29-8029.17.10 Income Allowances, Persons With LTC Status [50605] ..............29-8029.17.11 Maintenance Needs ....................................................................29-8029.17.12 Medicare .....................................................................................29-8129.17.13 Other Health Insurance Premiums..............................................29-8129.17.14 Therapeutic Wages .....................................................................29-8229.17.15 Upkeep of Home .........................................................................29-83

Criteria ...................................................................................29-83Allowances .............................................................................29-83Unavailabe Income ................................................................29-84

29.17.16 Support of a Disabled Relative....................................................29-84Criteria ...................................................................................29-84Allowance ...............................................................................29-84

29.17.17 Exempt Income ...........................................................................29-8429.17.18 Veterans’ Aid and Attendance - In LTC.......................................29-8429.17.19 Retroactive Payments .................................................................29-8529.17.20 Institutionalized Veteran with NO spouse/same-sex spouse/RDP

and/or Minor Child(ren) ....................................................................................29-86

29.17.21 Institutionalized Veteran with a spouse/same-sex spouse/RDP and/or Minor Child(ren) ....................................................................................29-86

29.17.22 $90 VA Pension, Veteran in LTC ................................................29-86

29.18 Budgeting ...................................................................................................29-86LTC Person with a Community Spouse ................................29-87

29.18.1 MC 176 M-LTC............................................................................29-8729.18.2 MC 176W Allocation/Special Deduction Worksheet....................29-88

MC 176 W, Worksheet A .......................................................29-88Part III. Allocation from Board and Care Person to spouse/same-sex spouse/RDP and/or Children at Home, or from LTC Person with No Community Spouse/Same-Sex Spouse/RDP to Children at Home 29-88

29.18.3 Use of the MC 176W, Allocation Special Deduction Worksheet-B ...............................................................................29-88

Part X: ....................................................................................29-8929.18.4 The “Allocation/ Special Deduction Worksheet” (MC 176W, Worksheet

B), is used to compute the allocation from the ABD (or MI) spouse/same-sex spouse/RDP to the community spouse/same-sex spouse/RDP. Follow these steps to compute the allocation from the LTC spouse/RDP/same-sex spouse:[ .........................................29-89

29.19 Budgeting Examples: .................................................................................29-9329.19.1 Long-Term Care (LTC) SOC Recomputation [50659]...............29-10929.19.2 Super-Liability Cases ...............................................................29-110



Definition ..............................................................................29-110Super-Liability Determination ...............................................29-110Per Diem Chart Rates ..........................................................29-110

29.20 Benefits Identification Card (BIC).............................................................29-112

29.21 Court Orders ............................................................................................29-11229.21.1 Craig v. Bonta ...........................................................................29-11229.21.2 Public Guardian Referral for Incompetent Clients.....................29-112

Long Term Care (LTC) Beneficiaries ...................................29-11329.21.3 Hunt v Kizer ..............................................................................29-11329.21.4 Johnson v Rank ........................................................................29-11429.21.5 Issue .........................................................................................29-11429.21.6 Decision ....................................................................................29-11429.21.7 Johnson v. Rank (Noncovered Medical Expenses of Persons in

Long-Term Care) ......................................................................29-114Necessary Noncovered Services .........................................29-115Payment for Necessary Noncovered Services ....................29-115“Important Notice About Your Medi-Cal Benefits” ................29-115Johnson v. Rank Payments to Beneficiary ..........................29-116

29.21.8 Pickle v. Rank ...........................................................................29-11629.21.9 Reese v Kizer ...........................................................................29-11629.21.10 Issue .........................................................................................29-11629.21.11 Decision ....................................................................................29-11629.21.12 LTC Prejudice Cases ................................................................29-11729.21.13 Issue .........................................................................................29-117

30. Medicare Coverage.........................................................................................30-1

30.1 Medicare - Part A & Part B...........................................................................30-130.1.1 Overview .......................................................................................30-130.1.2 Covered Services..........................................................................30-1

Part A .......................................................................................30-1Part B .......................................................................................30-1

30.1.3 Persons Eligible ............................................................................30-2Part A .......................................................................................30-2Part B .......................................................................................30-2

30.1.4 Premiums......................................................................................30-3Part A .......................................................................................30-3Part B .......................................................................................30-3

30.2 How Medicare And Medi-Cal Work Together...............................................30-430.2.1 Crossover Claims..........................................................................30-430.2.2 Medicare Deductibles ...................................................................30-530.2.3 Other Services ..............................................................................30-5



30.3 The Medicare Card.......................................................................................30-530.3.1 Description ....................................................................................30-530.3.2 Medicare Claim Number................................................................30-530.3.3 Issuance........................................................................................30-6

30.4 Persons Required to Apply for Medicare [50777].........................................30-730.4.1 General .........................................................................................30-730.4.2 Undocumented Non-Citizen ..........................................................30-730.4.3 Application Requirements .............................................................30-7

Part A .......................................................................................30-730.4.4 Acceptance ...................................................................................30-8

Part B .......................................................................................30-830.4.5 CalWIN..........................................................................................30-9

30.5 Verifying Application for Medicare [50777]...................................................30-930.5.1 SC 169 ..........................................................................................30-930.5.2 CalWIN Client Correspondence ....................................................30-930.5.3 Timeframes .................................................................................30-1030.5.4 Client Refusal ..............................................................................30-1030.5.5 Disenrollment ..............................................................................30-1030.5.6 Verifications.................................................................................30-10

30.6 Enrollment Periods .....................................................................................30-1130.6.1 Introduction .................................................................................30-1130.6.2 Initial Enrollment Period ..............................................................30-11

Persons Age 65 .....................................................................30-11Aged Noncitizens Who Meet Their 5 Years U.S. Residency .30-11Persons Eligible for Medi-Cal (ABD-MN/SSI/CALWORKS) ...30-12

30.6.3 General Enrollment Period ..........................................................30-12

30.7 Medicare Coding ........................................................................................30-12

30.8 Medi-Cal Beneficiaries with Medicare and Supplemental Insurance Coverage (OHC).................................................30-1330.8.1 Option..........................................................................................30-1330.8.2 Client and EW Action ..................................................................30-13

30.9 Medicare Buy-In .........................................................................................30-1430.9.1 Definition Of Buy-In [50777] ........................................................30-14

Part A .....................................................................................30-14Part B .....................................................................................30-14

30.9.2 Persons Eligible for “Buy-In” .......................................................30-1430.9.3 Persons Ineligible for “Buy-In” .....................................................30-1530.9.4 Individuals With SOC ..................................................................30-15

Voluntary Disenrollment .........................................................30-15Medicare Part B Enrollment Requirement .............................30-16Income Deduction ..................................................................30-16



Retroactive Reimbursement ..................................................30-16Budgeting ...............................................................................30-17Intake .....................................................................................30-17Continuing ..............................................................................30-17

30.9.5 Buy-In Procedures - Budgeting...................................................30-17Initiating Buy-In ......................................................................30-17Buy-In Effective Date .............................................................30-18Premium Reimbursement ......................................................30-19Verification .............................................................................30-19SOC Adjustment ....................................................................30-19

30.10 MEDS [INQB] Screen.................................................................................30-19

30.11 Buy-In Alerts/Messages ............................................................................30-2030.11.1 Requirements..............................................................................30-20

30.12 Use of the DHCS 6166...............................................................................30-2030.12.1 When to Use ...............................................................................30-2030.12.2 Situations Requiring the Use of the DHCS 6166 ........................30-2130.12.3 EW Action ...................................................................................30-2130.12.4 Completing the DHCS 6166........................................................30-2230.12.5 Contacting Medicare Buy In Unit ................................................30-2230.12.6 EW Follow-Up .............................................................................30-22

30.13 Medi-Cal Buy-In Chart................................................................................30-23Medi-Cal Buy-In Chart ...........................................................30-23

30.14 Medicare Savings Programs ......................................................................30-25

30.15 Qualified Medicare Beneficiary (QMB) Program ........................................30-2530.15.1 Background.................................................................................30-2530.15.2 General Eligibility Criteria............................................................30-2630.15.3 Two Basic Groups of QMBs........................................................30-2630.15.4 When to Evaluate for QMB .........................................................30-2730.15.5 Effective Date of Eligibility...........................................................30-28

Pre-Approved QMBs ..............................................................30-2930.15.6 Verification of Medicare Part A ...................................................30-2930.15.7 “Conditional” Medicare Part A.....................................................30-3030.15.8 MC 176 QMB-3 ...........................................................................30-3030.15.9 QMB Property Determination......................................................30-31

Rules ......................................................................................30-3230.15.10 Other Requirements....................................................................30-3330.15.11 Notices of Action .........................................................................30-34

Approvals ...............................................................................30-34Denials/ Discontinuances NOA ..............................................30-34Erroneous Discontinuance .....................................................30-35

30.15.12 ICTs ............................................................................................30-35



QMB Only ..............................................................................30-35SSI QMBs ..............................................................................30-35

30.15.13 SSI QMBs ...................................................................................30-36General ..................................................................................30-36Application Forms ..................................................................30-36SSI QMB Mail-In Referral Procedure .....................................30-36Other Referrals ......................................................................30-37Application Requirements ......................................................30-37Income Determination ............................................................30-38Verification of Medicare Part A ..............................................30-38Redetermination (RDs) ..........................................................30-39Discrepancies ........................................................................30-39Whereabouts Unknown Discontinuance ................................30-40

30.16 Specified Low-Income Medicare Beneficiary (SLMB) Program .................30-4030.16.1 Background .................................................................................30-4030.16.2 Effective Date..............................................................................30-4030.16.3 Benefit .........................................................................................30-4130.16.4 Eligibility Criteria..........................................................................30-41

Medicare Part A .....................................................................30-41Property .................................................................................30-41Income ...................................................................................30-42Citizen/ Noncitizen Status ......................................................30-42Other Requirements ...............................................................30-42

30.16.5 Dual Eligibility ..............................................................................30-43ABD-MN .................................................................................30-43SSI/SSPs, SLMB Does NOT Apply .......................................30-43

30.16.6 When to Evaluate........................................................................30-4330.16.7 NOAs...........................................................................................30-44

SLMB Only .............................................................................30-44ABD-MN and SLMB (Dual Eligibles) ......................................30-44

30.17 Qualifying Individual (QI-1) Program ..........................................................30-4430.17.1 Background .................................................................................30-4430.17.2 Overview .....................................................................................30-4530.17.3 Effective Date..............................................................................30-4530.17.4 Retroactive QI-1 Benefits ............................................................30-4530.17.5 Benefit .........................................................................................30-4530.17.6 Eligibility Criteria..........................................................................30-46

Medicare Part A .....................................................................30-46Property .................................................................................30-46Income ...................................................................................30-47Citizen/ Noncitizen Status ......................................................30-47Other Requirements ...............................................................30-47

30.17.7 When to Evaluate........................................................................30-4830.17.8 NOAs...........................................................................................30-48



30.17.9 Dual Eligibility..............................................................................30-48Rule .......................................................................................30-48

30.18 QMB/SLMB/QI Income Determination and Budgeting Rules.....................30-4930.18.1 Income Rules, General ...............................................................30-4930.18.2 Budgeting, MC 176-1 QMB/SLMB/QI .........................................30-4930.18.3 Budgeting, MC 176-2A QMB/SLMB/QI .......................................30-5030.18.4 IRWE...........................................................................................30-5130.18.5 QMB/SLMB/QI Budgeting Sequence Chart ................................30-52

30.19 Qualified Disabled Working Individuals (QDWI) Program..........................30-5530.19.1 Background.................................................................................30-5530.19.2 Effective Date..............................................................................30-5530.19.3 Benefit .........................................................................................30-5530.19.4 Medicare Part A ..........................................................................30-5530.19.5 Eligibility Criteria .........................................................................30-56

Conditions ..............................................................................30-56Other Requirements ..............................................................30-56Property Limit .........................................................................30-57Citizen/ Noncitizen Status ......................................................30-57Income Limit ..........................................................................30-57

30.20 Medicare Part D Prescription Drug Program............................................30-5830.20.1 Part D Enrollment........................................................................30-5830.20.2 Prescription Drug Plan (PDP) .....................................................30-5830.20.3 Enrollment in a Plan....................................................................30-59

Medicare Beneficiaries with Other Health Coverage (OHC) ..30-59Medicare Beneficiaries who Have Medigap Policies .............30-60

30.20.4 Costs...........................................................................................30-6030.20.5 Low Income Subsidy (LIS) Assistance........................................30-60

LIS and Medi-Cal Share-of-Cost (SOC) Calculation ..............30-6130.20.6 Responsible Agency ...................................................................30-6230.20.7 Information/Referral Resources ..................................................30-6230.20.8 Implementation ...........................................................................30-62

All Offices ...............................................................................30-62Eligibility Staff ........................................................................30-63Process Flow .........................................................................30-63

30.20.9 Santa Clara Family Health Plan (SCFHP) Medicare Plan ..........30-64

30.21 Medicare Plus Choice (M+C) Premium Payment Program........................30-64

30.22 Low Income Subsidy Applications..............................................................30-6530.22.1 Data Exchange ...........................................................................30-6530.22.2 Application Date..........................................................................30-6530.22.3 Denial ..........................................................................................30-6630.22.4 Processing Timeframe ................................................................30-6630.22.5 Retroactive Benefits ....................................................................30-67



30.22.6 Continuing / Pending Cases........................................................30-6730.22.7 Intake Process ............................................................................30-6730.22.8 Documentation ............................................................................30-7030.22.9 Forms ..........................................................................................30-70

31. Medically Needy (MN) & Medically Indigent (MI)..........................................31-1

31.1 AFDC-MN — Overview of Linkage...............................................................31-131.1.1 Definition .......................................................................................31-131.1.2 Nonparent Caretaker Relative (50085) .........................................31-2

Nonparent Caretaker Relative who is a Spouse or Parent ......31-231.1.3 Examples of Linkage.....................................................................31-2

Example 1: ...............................................................................31-2Example 2: ...............................................................................31-3Example 3: ...............................................................................31-3Example 4: ...............................................................................31-3Example 5: ...............................................................................31-4Example 6: ...............................................................................31-4Example 7: ...............................................................................31-4Example 8: ...............................................................................31-5

31.2 AFCD-MN (Non-MAGI) ................................................................................31-531.2.1 Who is eligible for the AFDC-MN program....................................31-531.2.2 Treatment of Income and Property for AFCD-MN.........................31-6

31.3 ABD-MN (Non-MAGI) Linkage .....................................................................31-631.3.1 General .........................................................................................31-631.3.2 Aged [50221].................................................................................31-731.3.3 Blind [50219] .................................................................................31-731.3.4 Disabled [50167, 50223] ...............................................................31-731.3.5 ABD Linkage Chart .......................................................................31-9

31.4 Cash/Medi-Cal Differences To Keep In Mind ...............................................31-931.4.1 Deprivation ..................................................................................31-1031.4.2 Linkage to Medi-Cal when the Only Child is on SSI/SSP............31-1031.4.3 No Work Registration Requirement.............................................31-1031.4.4 Medi-Cal Family Budget Unit (MFBU).........................................31-10

Unmarried Minor Parent in the Home ....................................31-10Caretaker Relative .................................................................31-11

31.4.5 Linkage When Parents are Sponsored Aliens ............................31-11

31.5 CalWORKs Case, Family Member Potentially Eligible for Medi-Cal........................................31-1131.5.1 CalWORKs Case Active -

Certain Family Members Ineligible or Excluded..........................31-1131.5.2 Entire CalWORKs Case to be Discontinued ...............................31-12



31.6 Medically Indigent Categories ....................................................................31-13

31.7 Property and Income..................................................................................31-13

31.8 Age.............................................................................................................31-14

31.9 MIA Exceptions ..........................................................................................31-14

31.10 Medically Indigent Child .............................................................................31-14

31.11 Blind or Disabled Child [50251]..................................................................31-15

31.12 Foster Children...........................................................................................31-15

31.13 Adopted Children .......................................................................................31-15

31.14 Other Foster/Adopted Children ..................................................................31-16

31.15 Processing MIA Applications......................................................................31-16

31.16 MIC or MIA Determination..........................................................................31-16

31.17 Treatment of MIA Pregnant Women and Their Newborns .........................31-1731.17.1 Verify Pregnancy and Expected Date of Confinement (EDC).....31-1731.17.2 Eligibility for MIA Pregnant Women ............................................31-1731.17.3 Determine Eligibility for the Newborn..........................................31-18

...............................................................................................31-18

32. 250% Working Disabled Program (250% WDP) ...........................................32-1

32.1 Definitions ....................................................................................................32-132.1.1 Child..............................................................................................32-132.1.2 Family Income...............................................................................32-132.1.3 In-Kind Support and Maintenance (ISM).......................................32-232.1.4 Presumed Maximum Value (PMV)................................................32-232.1.5 Substantial Gainful Activity (SGA) ................................................32-232.1.6 Spousal/Parental Deeming ...........................................................32-232.1.7 SSI/SSP ........................................................................................32-232.1.8 Value of the One -Third Reduction (VTR).....................................32-3

32.2 Eligibility Criteria...........................................................................................32-332.2.1 Disability Determination ................................................................32-432.2.2 Immigration Status ........................................................................32-432.2.3 Property Determination .................................................................32-532.2.4 Retained Earned Income ..............................................................32-532.2.5 Income Determination...................................................................32-6

SSI Income Test ......................................................................32-6250% Federal Poverty Level Test ............................................32-7

32.2.6 SSA Disability Income that Converts to Retirement Income.........32-8



32.3 Eligibility Determination Procedures.............................................................32-932.3.1 Identifying Potential Eligibles for the 250% WD Program .............32-932.3.2 Twenty-Six Weeks of Temporary Unemployment .......................32-1032.3.3 No Face-To-Face Requirement...................................................32-1032.3.4 Informing Requirement................................................................32-1032.3.5 Retroactive Benefits ....................................................................32-1132.3.6 Establishing a MEDS Record......................................................32-1132.3.7 Other Requirements....................................................................32-12

32.4 Monthly Premiums......................................................................................32-1232.4.1 Premium Amount Determination .................................................32-1232.4.2 Premium Collection System ........................................................32-13

Determining Eligibility and Amount of Premium .....................32-13Payment Options ...................................................................32-13Collection of Premiums ..........................................................32-14Third Party Liability Branch (TPLB) ........................................32-14Information Technology Services Division (ITSD) .................32-14

32.4.3 Termination of the 250% Working Disabled Program .................32-1532.4.4 Penalty Period.............................................................................32-15

32.5 Benefits Identification Card (BIC) ...............................................................32-15

32.6 Continuing Activities ...................................................................................32-1632.6.1 Status Reports ............................................................................32-1632.6.2 Redeterminations ........................................................................32-1632.6.3 Discontinuance for Reasons Other than Nonpayment of Premiums....

32-16

32.7 Notices of Action (NOAs) ...........................................................................32-16Notification .............................................................................32-16

32.8 SSI Methodology ........................................................................................32-1732.8.1 Determining Net Nonexempt Income ..........................................32-17

In-Kind Support and Maintenance (ISM) ................................32-17In-Kind Support and Maintenance - Sharing ..........................32-18Follow These Guidelines When Using the VTR and PMV Method .32-20

32.9 Budgeting Examples ..................................................................................32-2132.9.1 Example I - An Individual ............................................................32-2132.9.2 Example II - Child With Ineligible Parents ...................................32-2232.9.3 Example III - Eligible Individual With Ineligible Spouse (aged) ...32-24

33. Share of Cost (SOC) ......................................................................................33-1

33.1 Share of Cost (SOC)—Overview..................................................................33-133.1.1 Definition [50653] ..........................................................................33-1



33.1.2 When a Share of Cost Must Be Determined.................................33-1

33.2 Actions on the Share of Cost .......................................................................33-233.2.1 Client Responsibility [50657].........................................................33-233.2.2 Provider Responsibility [50657] ....................................................33-233.2.3 EW Responsibility [50657] ............................................................33-3

33.3 Change in the Share of Cost (SOC) ............................................................33-333.3.1 Changes Which Decrease the SOC ............................................33-333.3.2 Changes Which Increase the SOC ...............................................33-4

33.4 Processing Cases When the SOC is Retroactively Reduced ......................33-5

33.5 Reimbursement From The Provider.............................................................33-6

33.6 Case Situations ............................................................................................33-833.6.1 Adjustment of Future Share of Cost Amount ................................33-8

Case Situation 1 ......................................................................33-8Case Situation 2 ......................................................................33-9

33.6.2 Provider Reimbursement of Share of Cost ...................................33-9Case Situation 3 ......................................................................33-9Case Situation 4 ....................................................................33-10Case Situation 5 ....................................................................33-10Case Situation 6 ....................................................................33-11

33.6.3 Share of Cost Adjustment Over a Year Ago ...............................33-11Case Situation 7 ....................................................................33-11

33.7 Repayment of SOC for Poverty Level Program Eligibles...........................33-1333.7.1 FPL Program Effective Dates .....................................................33-1433.7.2 Share Of Cost Partially or Fully Met............................................33-14

Process (Less than 12 months)) ............................................33-14Process (More than 12 months) ............................................33-15

33.8 Hunt v. Kizer (Applying Old Medical Bills to the Share of Cost).................33-16

33.9 Policy..........................................................................................................33-1633.9.1 Exception ....................................................................................33-17

33.10 Definitions ..................................................................................................33-1733.10.1 Current Medical Bill .....................................................................33-1733.10.2 Old Medical Bill ...........................................................................33-1733.10.3 Month Incurred............................................................................33-1733.10.4 Unpaid, Old Medical Bill ..............................................................33-1733.10.5 Medical Bills, Medical Expenses.................................................33-18

33.11 Qualifying Criteria.......................................................................................33-1833.11.1 Liability for Debt ..........................................................................33-1833.11.2 One Time Only Rule ...................................................................33-19



33.11.3 Other Health Coverage ...............................................................33-1933.11.4 MFBU ..........................................................................................33-1933.11.5 IHSS............................................................................................33-1933.11.6 Interest Charges..........................................................................33-1933.11.7 No Payment Required.................................................................33-19

33.12 Verification Requirements ..........................................................................33-2033.12.1 Original Medical Bills ...................................................................33-2033.12.2 “Original” Bills versus Photocopies..............................................33-2133.12.3 Other Substitute Billing Statements ............................................33-2133.12.4 Contact to Provider .....................................................................33-2133.12.5 Affidavit .......................................................................................33-2233.12.6 Credit Card Statements...............................................................33-22

33.13 Incomplete Information...............................................................................33-23

33.14 Denial of Medical Bill(s)..............................................................................33-23

33.15 Limitations on SOC Adjustments................................................................33-2433.15.1 Must Meet SOC...........................................................................33-2433.15.2 Future Use ..................................................................................33-2433.15.3 Consecutive Months....................................................................33-2533.15.4 Past Months ................................................................................33-25

33.16 SOC Adjustment ........................................................................................33-25Paid or Unpaid Current Month’s Medical bills ........................33-25Unpaid Old Medical Bills ........................................................33-26Methods of SOC Adjustment .................................................33-26

33.16.1 CalWIN Adjustment .....................................................................33-2633.16.2 Adjustments through MEDS........................................................33-27

33.17 Discontinued Cases ...................................................................................33-27

33.18 Examples....................................................................................................33-2833.18.1 Intake ..........................................................................................33-28

SOC Applicant, No Retroactive Coverage .............................33-28SOC Applicant, Retroactive Coverage Requested ................33-28

33.18.2 Continuing ...................................................................................33-29Saving Old and Current Bills to Apply in a Future Month .......33-29Ineligible Member of MFBU ...................................................33-29

33.18.3 Intake and/or Continuing .............................................................33-29Client Fails to Provide Timely Documentation .......................33-29Old Medical Expenses for Persons No Longer in the MFBU .33-29

34. 1931(b) .............................................................................................................34-1

34.1 Background ..................................................................................................34-1



34.2 Section 1931(b) General Rules....................................................................34-2

34.3 Definitions ....................................................................................................34-334.3.1 Applicant .......................................................................................34-334.3.2 Disability-Based Income (DI) ........................................................34-334.3.3 Earned Income..............................................................................34-434.3.4 Recipient .......................................................................................34-434.3.5 Responsible Relative ....................................................................34-4

34.4 Forms ...........................................................................................................34-5

34.5 Section 1931(b) Eligibility Determination .....................................................34-6

34.6 3-Months Retroactive Section 1931(b) Medi-Cal .........................................34-634.6.1 General Rule.................................................................................34-734.6.2 EXAMPLES...................................................................................34-734.6.3 Late Requests for Retro................................................................34-8

Example: ..................................................................................34-8

34.7 General Eligibility Procedures ......................................................................34-9

34.8 Section 1931(b) Screening Criteria ............................................................34-1034.8.1 Age..............................................................................................34-10

Unborn ...................................................................................34-11

34.9 Deprivation .................................................................................................34-1134.9.1 Deceased Parent Deprivation[50209] .........................................34-1134.9.2 Absent Parent (A/P) Deprivation.................................................34-12

Continued Absence ...............................................................34-12Temporary Absence ..............................................................34-12Establishing A/P Deprivation .................................................34-13Who is Linked to A/P Deprivation ..........................................34-13

34.9.3 Incapacitated Parent Deprivation [50211] ...................................34-14Establishing Incapacitated Parent Deprivation ......................34-14

34.9.4 Unemployed Parent Deprivation [50215] ....................................34-15Rule .......................................................................................34-15Conditions of an Unemployed Parent ....................................34-15Principal Wage Earner (PWE) ...............................................34-16EXAMPLES ...........................................................................34-16MC 210 S-W ..........................................................................34-17U/P Income Test ....................................................................34-18Procedure ..............................................................................34-19Who is Linked to U/P Deprivation ..........................................34-19EXAMPLE 1: ..........................................................................34-20EXAMPLE 2: ..........................................................................34-20EXAMPLE 3: ..........................................................................34-20EXAMPLE 4: ..........................................................................34-20



34.9.5 Property.......................................................................................34-2134.9.6 Income ........................................................................................34-21

34.10 MFBU Determination..................................................................................34-2134.10.1 General Section 1931(b) MFBU Rules........................................34-2134.10.2 Mixed Household Situations........................................................34-22

Section 1931(b) & MN/MI Medi-Cal .......................................34-22Section 1931(b) & FPL Medi-Cal ...........................................34-23

34.10.3 MFBUs Containing Stepparents..................................................34-24Stepparent’s Non-Cooperation ..............................................34-24

34.10.4 Excluded Child ............................................................................34-2434.10.5 Pregnant Woman ........................................................................34-25

Pregnant Woman With No Other Children .............................34-25Father of the Unborn in the Home With No Other Deprived Children 34-25Pregnant Woman With Other Children ..................................34-26

34.10.6 Care and Control .........................................................................34-2634.10.7 Caretaker Relatives.....................................................................34-27

MFBU Requirements .............................................................34-27More Than One Non-Parent Caretaker Relative and Related Children ..................................................................................34-27Option to be Linked to Related Children or Own Children .....34-27Adult Parent with Children Living with a Caretaker Relative ..34-29Non-Needy Caretaker’s Related Children Receiving CalWORKs ..34-30

34.10.8 No Caretaker Relative.................................................................34-3034.10.9 Senior Parent/Minor Parent Cases .............................................34-30

MFBU Rules for Senior/Minor Parent Cases .........................34-31Examples of Minor Parent Cases ..........................................34-33

34.10.10 PA/Other PA................................................................................34-34

34.11 Section 1931(b) Income Limits and Tests ..................................................34-35

34.12 Types of Income.........................................................................................34-3634.12.1 CalWORKs Diversion Payments .................................................34-3634.12.2 CalWORKs Special Needs Payment...........................................34-3634.12.3 Disability-Based Income (DI).......................................................34-3634.12.4 Earned Income............................................................................34-3734.12.5 Income In-Kind Values for Section 1931(b) ................................34-3734.12.6 WIA (Workforce Investment Act) .................................................34-3734.12.7 Lump Sum Income ......................................................................34-37

34.13 Treatment of Income ..................................................................................34-3834.13.1 Actual Income [50517] ................................................................34-3834.13.2 Treatment of Apportioned Income [50517]..................................34-38

Earned Income Received in More Than Eight but Less Than



Twelve Months .......................................................................34-38Income Received Other Than Monthly or Semi-Monthly .......34-38

34.13.3 Income Allocation Rules - Section 1931(b) and MN/MI Medi-Cal.........................................34-39

Section 1931(b) Eligibles .......................................................34-39Child .......................................................................................34-39Adult .......................................................................................34-40

34.14 Section 1931(b) Income Deductions ..........................................................34-4034.14.1 $240/$120 Deduction..................................................................34-4034.14.2 50 Percent Deduction .................................................................34-4134.14.3 $90 Work Related Expense (WRE) ............................................34-4134.14.4 Allocation to an Excluded Child ..................................................34-4234.14.5 Court Ordered Child/Spousal Support ........................................34-4234.14.6 Dependent Care..........................................................................34-4234.14.7 Educational Expenses ................................................................34-4234.14.8 Health Insurance Premium Deduction ........................................34-4334.14.9 Income Counted by Public Assistance Programs .......................34-4334.14.10 Property Expenses - Income from Property ................................34-4334.14.11 Self-Employment Income Deduction/Allowable Expenses..........34-43

34.15 How to Apply the 240 + 1/2 Deduction in the MBSAC TEST ............................................................................................34-45

MFBUs With No More than Two Persons with Earnings .......34-45MFBUs with Three or More Persons with Earnings ...............34-45

34.16 Determining Income Eligibility ....................................................................34-4634.16.1 Section 1931(b) 100% FPL Test .................................................34-4634.16.2 Section 1931(b) MBSAC Test .....................................................34-47

34.17 MFBU and Linkage Examples...................................................................34-5034.17.1 Some Family Members Receive CalWORKs..............................34-5034.17.2 CalWORKs Discontinued Because of Earnings..........................34-5034.17.3 Husband, Wife, Two Mutual Children,

Husband’s Separate Child, Wife’s Separate Child......................34-52EXAMPLE 1: ..........................................................................34-52EXAMPLE 2: ..........................................................................34-53

34.17.4 Family Members Living in the Home Who are Not PA or Other PA.....34-54

Example 1: .............................................................................34-54Example 4: .............................................................................34-56Example 5: .............................................................................34-57Example 6: .............................................................................34-57

34.17.5 Family Members Living in the Home Who are PA or Other PA ..34-5834.17.6 Senior Parent/Minor Parent Situations........................................34-60

Example 1: .............................................................................34-60



Example 2: .............................................................................34-61Example 3: .............................................................................34-62

34.17.7 Married Pregnant Woman with No Other Children......................34-6234.17.8 Essential Person .........................................................................34-63

34.18 Income Allocation Examples ......................................................................34-6334.18.1 Income Allocation: Non-Sneede Case ........................................34-63

Married Couple, 2 Mutual Children, 2 Separate Children ......34-6334.18.2 Income Allocation: Sneede Case ................................................34-64

Married Couple, 2 Mutual Children, 2 Separate Children ......34-64

34.19 Property Limit .............................................................................................34-6834.19.1 Excess Property ..........................................................................34-68

34.20 Determining the Property Reserve .............................................................34-6934.20.1 Property Which Must Be Considered ..........................................34-6934.20.2 “Section 1931(b) Property Reserve Worksheet”

(SC 1931-P) ................................................................................34-69

34.21 Treatment of Property ................................................................................34-7034.21.1 Unavailable Property ...................................................................34-70

Informing Requirement ..........................................................34-7034.21.2 Property of Insignificant Value ....................................................34-71

Any significant amount of funds .............................................34-71Significant return ....................................................................34-71

34.21.3 Exempt Property .........................................................................34-71

34.22 Motor Vehicles............................................................................................34-7234.22.1 Exempt Vehicles .........................................................................34-73

Licensed Motor Vehicles ........................................................34-73Unlicensed Motor Vehicle ......................................................34-74

34.22.2 Determining the Value of a Non-exempt Vehicle ........................34-74Excess Fair Market Value (FMV) ...........................................34-74Equity Value ...........................................................................34-74

34.22.3 Value to Use in Property Reserve...............................................34-7534.22.4 “Section 1931(b) Vehicle Determination Worksheet”

(SC 1931-V) ................................................................................34-75

34.23 Personal Property.......................................................................................34-7534.23.1 Determining the Value of Personal Property ...............................34-75

Fair Market Value ...................................................................34-75Net Market Value ...................................................................34-76

34.23.2 Treatment of Personal Property ..................................................34-76

34.24 Real Property .............................................................................................34-7934.24.1 Exempt and Unavailable Real Property ......................................34-79

Principal Residence ...............................................................34-79



The Home During a Marital Separation .................................34-79Real Property Listed For Sale ................................................34-80

34.24.2 Determining the Value of Real Property .....................................34-81Fair Market Value ..................................................................34-81Net Market Value ...................................................................34-82

34.25 Transfers of Property .................................................................................34-82

34.26 Section 1931(b) - Sneede ..........................................................................34-8234.26.1 Sneede Property Methodology ...................................................34-8334.26.2 Sneede Budgeting Methodology.................................................34-83

34.27 Transitional Medi-Cal for Section 1931(b) (Aid Codes 39 and 59) ...............................................................................34-8434.27.1 CalWORKs Discontinuance and Section 1931(b) or TMC..........34-84

34.28 Four-Month Continuing Eligibility (Aid Code 54) ........................................34-85

34.29 Comparison Chart - Section 1931(b) & AFDC-MN ....................................34-86

35. Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC) 35-1

35.1 Overview - Continued Eligibility for Pregnant Women and Infants ..............35-135.1.1 Affected Persons...........................................................................35-235.1.2 Eligibility, General .........................................................................35-335.1.3 Eligibility for Pregnant Women......................................................35-335.1.4 Adding Newborns, General ...........................................................35-435.1.5 Newborn Referral Form (MC 330).................................................35-4

Background ..............................................................................35-4Newborn Referral Procedure-Provider ....................................35-5Newborn Referral Procedure ...................................................35-5Medi-Cal Notice of Newborn Referral Form (SCD 1374) .........35-6

35.1.6 Unmarried Fathers - MN/MI Medi-Cal ...........................................35-7MFBU .......................................................................................35-7Income/Property ......................................................................35-7U-Parent Linkage .....................................................................35-7Information Provided ................................................................35-8

35.1.7 Sneede..........................................................................................35-835.1.8 Medical Support Enforcement.......................................................35-935.1.9 Three Month Retroactive ..............................................................35-9

Example 1: .............................................................................35-1035.1.10 Break In Aid ................................................................................35-1035.1.11 Intercounty Transfers (ICTs) .......................................................35-1035.1.12 Whereabouts Unknown...............................................................35-1035.1.13 Annual Redeterminations............................................................35-1135.1.14 Increased Income, Pregnant Woman (MN/MI Programs) ...........35-12



35.1.15 Increased Income, Infants (MN/MI Programs) ............................35-1335.1.16 Increased Income,

PA/Other PA Recipients/Section 1931(b) ...................................35-1335.1.17 Determining MFBUs/SOC ...........................................................35-14

Example 1 ..............................................................................35-14Example 2 ..............................................................................35-15Example 3 ..............................................................................35-15Example 4 ..............................................................................35-16Change in MFBU Size ...........................................................35-16

35.2 Deemed Eligibility for Infants......................................................................35-1635.2.1 Overview .....................................................................................35-1635.2.2 Program Eligibility .......................................................................35-17

Residency ..............................................................................35-17Deficit Reduction Act (DRA) of 2005 ......................................35-18Infants Born to Minor Consent Mothers .................................35-18Infant Born to Youths Receiving Adoption Assistance Program (AAP) Benefits .......................................................................35-18

35.2.3 Retroactive Eligibility ...................................................................35-19Example 1: .............................................................................35-19Example 2: .............................................................................35-19Example 3: .............................................................................35-20Example 4: .............................................................................35-20

35.2.4 Infant’s SOC/No SOC .................................................................35-20Example 1: Mother eligible for no SOC Restricted Benefits ..35-21Example 2: Mother Eligible for no SOC Medi-Cal ..................35-21Example 3: Mother’s SOC Unmet in the Birth Month .............35-21Example 4: Mother’s SOC Met in the Birth Month: ................35-21Example 5: Mother’s SOC Reduced ......................................35-22Example 6: Mother Met Her SOC in the Birth Month, Change in MFBU .....................................................................................35-22

35.2.5 Expedited Enrollment ..................................................................35-2335.2.6 Activating DE for the Infant .........................................................35-2435.2.7 Reporting Requirements .............................................................35-2435.2.8 Change in County of Residence .................................................35-2435.2.9 DE Infant Approaches Age One Year .........................................35-25

Example: ................................................................................35-2535.2.10 Discontinued Family Reapplies During SB 87 Process...............35-2535.2.11 Rescind DE Due to Loss of Contact............................................35-26

Example 1: .............................................................................35-26Example 2: .............................................................................35-26

35.3 CHDP Gateway DE Infant Enrollment Process..........................................35-2735.3.1 MEDS Alerts................................................................................35-2735.3.2 Exception Eligibles Report ..........................................................35-28



35.4 Continuous Eligibility for Children (CEC) ...................................................35-2935.4.1 CEC Program Eligibility Rules.....................................................35-2935.4.2 CEC Exceptions..........................................................................35-3035.4.3 The 12 Month CEC Period..........................................................35-3035.4.4 Guaranteed CEC Period .............................................................35-3035.4.5 CEC Aid Codes...........................................................................35-3135.4.6 Changes Reported During The CEC Period ...............................35-31

Decrease in Income Reported in SOC Month Prior to Annual RD .35-32

35.4.7 Ineligibility for All Medi-Cal Programs after CEC ends................35-32Healthy Kids ...........................................................................35-32

35.4.8 Annual Redetermination Following a Period of CEC ..................35-3335.4.9 CEC Retroactive Eligibility ..........................................................35-33

SOC in Month of Application and Zero SOC in Retroactive Month 35-33Eligibility Established Prior to Retroactive Request ...............35-34CEC Begins in a Retro Month/CEC Guaranteed Period Ends Prior to RD ......................................................................................35-34Examples of Retroactive CEC ...............................................35-35

35.4.10 Linkage to Section 1931(b) Medi-Cal Program...........................35-3635.4.11 CEC for Infants Under Age One .................................................35-36

DE Eligible Infant No Longer Residing With Medi-Cal Eligible Mother ....................................................................................35-37

35.4.12 Children Discontinued from CalWORKs .....................................35-3735.4.13 Children Losing Foster Care Eligibility ........................................35-3735.4.14 Children Losing SSI Cash-Based Medi-Cal ................................35-3835.4.15 CEC and Transitional Medi-Cal (TMC) .......................................35-38

TMC and 1931(b) Recipients .................................................35-38Impact of CEC on TMC ..........................................................35-39

35.4.16 CEC Procedures .........................................................................35-3935.4.17 Redeterminations Not Completed Timely ...................................35-4035.4.18 Intercounty Transfers ..................................................................35-4135.4.19 CEC When a Child Leaves the Home.........................................35-4135.4.20 Discontinuance for Whereabouts Unknown................................35-4235.4.21 Request for CEC Discontinuance ...............................................35-42

35.5 Extended Medi-Cal Eligibility for Former Foster Youth (FFY) 18 to 26 Years of Age.............................................................................................................35-4335.5.1 Background.................................................................................35-4335.5.2 Who is Eligible ............................................................................35-44

Eligible Youth 18-26 ...............................................................35-4435.5.3 Youth Not Eligible for FFY ..........................................................35-4535.5.4 General Eligibility Rules ..............................................................35-45

Deemed Eligible Infant with FFY Youth .................................35-4735.5.5 FFY and CalHEERS ...................................................................35-4835.5.6 Hospital Presumptive Eligibility Program ....................................35-49



35.5.7 Self Attestation ............................................................................35-49Not Eligible for FFY ................................................................35-50

35.5.8 MFBU Rules................................................................................35-5135.5.9 Income of FFY Child Who Resides With Their Parents and Other

Family Members..........................................................................35-5135.5.10 Retroactive Eligibility ...................................................................35-5135.5.11 FFY and CalWORKs ...................................................................35-5235.5.12 FFY and SSI................................................................................35-5235.5.13 District Office Procedures ...........................................................35-53

Application Process ...............................................................35-53Forms/Verifications/Notices of Action (NOAs) .......................35-53Phone Application Requests ..................................................35-54Independent Living Program (ILP) .........................................35-54NOAa .....................................................................................35-54

35.5.14 Redeterminations ........................................................................35-5535.5.15 No Longer Eligible for FFY Medi-Cal and Approach 26 ..............35-56

36. FPL Programs .................................................................................................36-1

36.1 60-Day Postpartum Program........................................................................36-136.1.1 Program Overview ........................................................................36-136.1.2 Eligibility Requirements.................................................................36-136.1.3 Period of Eligibility .........................................................................36-236.1.4 Dual Eligibility and Postpartum .....................................................36-236.1.5 Pregnancy Definition/Verification Requirements ...........................36-236.1.6 Women Eligible for 60-Day Postpartum ........................................36-3

Medically Indigent (MI) Women (e.g. Aid Code 86, 87) ...........36-3Medically Needy (MN) Women (e.g., Aid Code 34, 37) ...........36-3Public Assistance (PA) or Other PA Recipient (TMC) .............36-4Minors, Whose Pregnancy Terminates ....................................36-4

36.1.7 Women Ineligible for 60-Day Postpartum......................................36-536.1.8 Issuing Postpartum When Pregnancy Ends..................................36-636.1.9 Discontinuance of 60-Day Postpartum Benefits............................36-7

36.2 Income Disregard Program ..........................................................................36-936.2.1 Who is Eligible...............................................................................36-936.2.2 Background .................................................................................36-1036.2.3 Retroactive Benefits ....................................................................36-1036.2.4 Period of Eligibility .......................................................................36-10

Pregnant Women ...................................................................36-10Infants ....................................................................................36-11

36.2.5 Scope of Benefits and Aid Codes ...............................................36-11Pregnant Women ...................................................................36-11Infants ....................................................................................36-12

36.2.6 Income Determination, Budgeting...............................................36-1236.2.7 Pregnant Minors, Parental Income Disregard .............................36-13



36.2.8 Approvals & Denials....................................................................36-1436.2.9 Exceptions ..................................................................................36-14

Continued Eligibility ...............................................................36-14Property Waiver Program ......................................................36-15

36.2.10 MFBU Requirements ..................................................................36-15Pregnant Women ...................................................................36-15Infants ....................................................................................36-15

36.2.11 MFBU Examples .........................................................................36-1636.2.12 Notices of Action .........................................................................36-26

Approvals ...............................................................................36-26Discontinuances ....................................................................36-27Discontinuance of Income Disregard & Another Program .....36-27Denials ...................................................................................36-27

36.2.13 Minor Consent.............................................................................36-2836.2.14 Hospitalized Infants.....................................................................36-2836.2.15 Midyear Status Report (MSR).....................................................36-29

36.3 133% Program for Children Ages One Through Five ................................36-3036.3.1 Definition .....................................................................................36-3036.3.2 Application for the 133% Program ..............................................36-30

Intake .....................................................................................36-30Continuing Cases ..................................................................36-31

36.3.3 Period of Eligibility.......................................................................36-3136.3.4 Scope of Benefits ........................................................................36-3236.3.5 Eligibility Determination...............................................................36-3236.3.6 Approvals and Denials ................................................................36-3336.3.7 MFBU Requirements ..................................................................36-34

MFBU Example: .....................................................................36-3436.3.8 Notice of Action Requirements ...................................................36-35

Approval of Benefits ...............................................................36-35Discontinuance of 133% Benefits Only ..................................36-35

36.4 100% Program ...........................................................................................36-3536.4.1 Who is Eligible ............................................................................36-3536.4.2 Effective Date..............................................................................36-3636.4.3 Period of Eligibility.......................................................................36-3636.4.4 Scope of Benefits ........................................................................36-3736.4.5 Eligibility Determination...............................................................36-3736.4.6 Approvals & Denials....................................................................36-3836.4.7 MFBU Requirements ..................................................................36-3836.4.8 Notice of Action Requirements ...................................................36-38

Approval of Benefits ...............................................................36-38Discontinuance of 100% Benefits Only ..................................36-39

36.5 Property Waiver Program...........................................................................36-4036.5.1 Background.................................................................................36-40



36.5.2 Property Waiver Program Criteria ...............................................36-41Pregnant Women and Infants ................................................36-41Children One to Six Years .....................................................36-41Children Six to Nineteen ........................................................36-42

36.5.3 Scope of Coverage .....................................................................36-4236.5.4 Property Verification Not Required..............................................36-4336.5.5 Income Generated From Waived Property..................................36-43

Rental Income from Real Property .........................................36-4336.5.6 Determining Eligibility for Property Waiver ..................................36-44

Zero Share-of-Cost and Property Waiver ..............................36-4536.5.7 Denials ........................................................................................36-4636.5.8 Discontinuance............................................................................36-4636.5.9 Property Changes .......................................................................36-4736.5.10 Income Increases........................................................................36-47

Pregnant women and Infants are exempt ..............................36-4736.5.11 Examples ....................................................................................36-47

Pregnant Woman with an Absent Parent ...............................36-47Unmarried Couple with an Unborn .........................................36-48Married Couple with Mutual Children, Continuing Case ........36-48Unmarried Mother Applicant With Two Children ....................36-49

36.6 Targeted Low-Income Children’s Program (TLICP) ...................................36-5036.6.1 Background .................................................................................36-5036.6.2 Who is Eligible.............................................................................36-5036.6.3 Application for the TLICP ............................................................36-5036.6.4 Scope of Benefits ........................................................................36-5136.6.5 Premiums ....................................................................................36-54

Premium Collection ................................................................36-54Missed Payments ...................................................................36-54Non-Payment of Premium Process ........................................36-55Premium Waiver and Refund Requests .................................36-59

36.6.6 Bridging for AIM-Linked Infant.....................................................36-62

37. Transitional Medi-Cal (TMC) ..........................................................................37-1

37.1 Overview [50244] .........................................................................................37-137.1.1 Who Qualifies for TMC..................................................................37-2

Qualifying Criteria for Discontinued CalWORKs/Section 1931(b) ..37-3Non-Qualifying CalWORKs/Section 1931(b) Discontinuance Reasons ...................................................................................37-4Definitions/ Who Qualifies for TMC ..........................................37-5

37.1.2 Ineligible Persons..........................................................................37-637.1.3 Adding a Person to Existing TMC .................................................37-737.1.4 Persons Leaving the Home...........................................................37-837.1.5 MFBU Composition .......................................................................37-8



Optional Members ...................................................................37-937.1.6 Return to CalWORKs or Section 1931(b) .....................................37-937.1.7 EW Procedures/Responsibility....................................................37-1037.1.8 TMC Informing Flyer ...................................................................37-11

37.2 Initial Six Months of TMC (39/3T)...............................................................37-11Reduction in Initial TMC Months ............................................37-12

37.3 Additional Six Months of TMC (59/5T) .......................................................37-12

37.4 TMC Status Report ....................................................................................37-1437.4.1 Good Cause Determinations.......................................................37-1537.4.2 Incomplete TMC Status Reports .................................................37-1637.4.3 Status Report Verification Requirements....................................37-1637.4.4 Nonexempt Earned Income ........................................................37-1737.4.5 Determining Average Net-Nonexempt Earned Income...............37-18

TMC Status Report Worksheet ..............................................37-18

37.5 Termination of Initial/Additional TMC .........................................................37-20

37.6 Redetermination Due to Loss of TMC Eligibility.........................................37-21Processing the Redetermination Packet ................................37-21

37.7 Initial and Additional TMC Discontinuance NOA........................................37-23

37.8 Conversion After TMC Discontinuance ......................................................37-23

37.9 Questions and Answers .............................................................................37-24

37.10 Four-Month Continuing ..............................................................................37-2637.10.1 Background.................................................................................37-2637.10.2 Policy ..........................................................................................37-2637.10.3 Four Month Continuing Requirements ........................................37-2737.10.4 Ineligibility for Four Month Continuing.........................................37-2737.10.5 Period of Eligibility.......................................................................37-2837.10.6 EW Responsibility .......................................................................37-28

37.11 Edwards v. Kizer ........................................................................................37-2937.11.1 Background.................................................................................37-2937.11.2 Persons Affected.........................................................................37-30

RCA/ECA and Edwards .........................................................37-3037.11.3 Auto CalWIN/MEDS Conversion.................................................37-3037.11.4 General Requirements................................................................37-3137.11.5 Discontinuing INDIVIDUALS from CalWORKs/RCA/ECA ..........37-3137.11.6 Discontinuing CalWORKs/RCA/ECA Case, Information on File .37-3337.11.7 MFBU Considerations.................................................................37-33

37.12 Bridging Program (7X) ...............................................................................37-34



37.13 Healthy Families to Medi-Cal PE Program.................................................37-3437.13.1 Background .................................................................................37-34

37.14 Kaiser Dues Subsidy Program ...................................................................37-3537.14.1 Definition .....................................................................................37-3537.14.2 Eligibility Criteria..........................................................................37-3537.14.3 How To Apply ..............................................................................37-36

37.15 Kaiser Permanente Steps Plan ..................................................................37-3637.15.1 Eligibility Criteria..........................................................................37-3637.15.2 Income Limit ................................................................................37-3737.15.3 How to Apply ...............................................................................37-37

38. Minor Consent.................................................................................................38-1

38.1 Background ..................................................................................................38-138.1.1 State Law [50147.1 Proc. 19B-1] ..................................................38-1

38.2 Definition of Minor Consent Services [50063.5] ...........................................38-138.2.1 Definition of “Child” for Minor Consent [50030, 50351] .................38-2

38.3 Who Can Apply ............................................................................................38-338.3.1 A Child [50147.1, 50163 Proc. 19-B].............................................38-338.3.2 Incompetent Child .........................................................................38-338.3.3 Parents on Behalf of Competent Child ..........................................38-438.3.4 Adults [50147.1] ............................................................................38-438.3.5 Other Services ..............................................................................38-4

38.4 Application Requirements ............................................................................38-538.4.1 Forms ............................................................................................38-5

MC 4026 ..................................................................................38-538.4.2 Mental Health Statement...............................................................38-638.4.3 Notices of Action ...........................................................................38-738.4.4 Confidentiality................................................................................38-738.4.5 Period of Eligibility .........................................................................38-8

38.5 Eligibility Criteria [50147.1, 50167, 50191, 50301, 50351, 50373, 50509, 50603, MEPM 15-A,19-A] ........................................................................................38-838.5.1 General Rule .................................................................................38-838.5.2 Citizenship/Alien Status ................................................................38-838.5.3 Identity...........................................................................................38-938.5.4 Responsible Relatives...................................................................38-938.5.5 OHC ..............................................................................................38-938.5.6 Health Care Options....................................................................38-1038.5.7 Income ........................................................................................38-1138.5.8 Maintenance Need ......................................................................38-1138.5.9 Property.......................................................................................38-11



38.5.10 MFBU Rules................................................................................38-1138.5.11 Minor Consent Aid Codes ...........................................................38-1238.5.12 Status Reports ............................................................................38-1338.5.13 Reporting Responsibility .............................................................38-13

38.6 Pregnant Minors.........................................................................................38-1338.6.1 Verification Not Required for Pregnancy.....................................38-1338.6.2 MFBU Considerations.................................................................38-1438.6.3 Income Disregard Program.........................................................38-1438.6.4 Pregnant Minor Needing Other Than Pregnancy Scope of

Services/MFBU Considerations ..................................................38-15No share of cost .....................................................................38-15Share of cost ..........................................................................38-15

38.6.5 Continued Eligibility (CE) ............................................................38-15Mothers ..................................................................................38-15Infants ....................................................................................38-16

38.6.6 Postpartum Benefits....................................................................38-16

38.7 Mental Health Applicants ...........................................................................38-1738.7.1 Applicants ...................................................................................38-1738.7.2 Mental Health Treatment Limitations ..........................................38-18

38.8 Issuance Procedures [50147.1] .................................................................38-1838.8.1 Paper BIC ...................................................................................38-1838.8.2 Issuing Benefits...........................................................................38-1938.8.3 Reapplications/Subsequent Certifications ..................................38-2038.8.4 Adding Minor Mother to Her Child's Case...................................38-2038.8.5 ICT ..............................................................................................38-21

38.9 CalWIN/MEDS Information ........................................................................38-2138.9.1 Approvals in CalWIN...................................................................38-2138.9.2 MEDS Online Procedures (Proc. 19-B).......................................38-2238.9.3 BIC Mail Procedures ...................................................................38-22

38.10 Child Abuse Reporting Requirements........................................................38-2338.10.1 Mandatory Reporting ..................................................................38-2338.10.2 Reporting Numbers.....................................................................38-23

39. ....................................................... Specific Institutional Programs [50273]39-1

39.1 Pre-Release Application Process for Incarcerated Individuals ....................39-139.1.1 Application Process Summary of Responsibilities ........................39-1

CDCR and SD .........................................................................39-1SSA ..........................................................................................39-4SSA and CDCR .......................................................................39-5

39.1.2 Application procedures .................................................................39-639.1.3 Inmate Pre-Release Questions and Answers ...............................39-8



39.2 SB 1469 Pre-Release Application Process for Wards in County Juvenile Facilities .....................................................................................................39-1139.2.1 Program Overview ......................................................................39-1139.2.2 SB 1469 Application Process......................................................39-1239.2.3 Eligibility Requirements...............................................................39-1339.2.4 VMC Intake Procedures ..............................................................39-14

39.3 Medi-Cal Inmate Eligibility Program (MCIEP) ............................................39-1739.3.1 Background .................................................................................39-1739.3.2 MCIEP Overview.........................................................................39-1739.3.3 Eligibility Requirements..............................................................39-1839.3.4 Summary of Responsibilities .......................................................39-1839.3.5 County Involvement with MCIEP State Inmates..........................39-19

MCIEP Beneficiary Applies for MC ........................................39-2039.3.6 State Inmate Aid Codes ..............................................................39-2139.3.7 County Inmate Aid Codes ...........................................................39-2239.3.8 Medical Parole ............................................................................39-2339.3.9 State Inmate Aid Codes for Medical Parole ................................39-2539.3.10 County Medical Probation/Compassionate Release...................39-2539.3.11 County Inmate Aid Code Medical Probation and Compassionate

Release .......................................................................................39-2639.3.12 MCIEP Application Procedures...................................................39-28

39.4 Institution Definitions ..................................................................................39-2939.4.1 Fleeing Felon ..............................................................................39-2939.4.2 Inmate .........................................................................................39-2939.4.3 Institution.....................................................................................39-2939.4.4 Medical Institution .......................................................................39-2939.4.5 Non-medical Institution................................................................39-3039.4.6 Tuberculosis Institution ..............................................................39-30

39.5 Public Institutions .......................................................................................39-30

39.6 Not Public Institutions.................................................................................39-3139.6.1 Medical institution........................................................................39-3139.6.2 Intermediate care facility .............................................................39-3139.6.3 Child Care Institution...................................................................39-3139.6.4 Institution for the Mentally Retarded ...........................................39-3139.6.5 Community Care Facility .............................................................39-3239.6.6 Publicly Operated Community Residence...................................39-33

39.7 Inmates of a Public Institutions...................................................................39-3439.7.1 Inmates Who May be Eligible for Medi-Cal Benefits ...................39-3439.7.2 Inmates Ineligible for Medi-Cal Benefits......................................39-3539.7.3 Inmates Under Penal Code.........................................................39-37

39.8 Alternatively Sentenced..............................................................................39-38



Situation # 1: ..........................................................................39-38Situation # 2: ..........................................................................39-38Situation # 3: ..........................................................................39-39Situation # 4: ..........................................................................39-39

39.9 Juveniles in Public Institutions ...................................................................39-3939.9.1 Disposition ..................................................................................39-3939.9.2 Before Disposition.......................................................................39-4039.9.3 After Disposition..........................................................................39-4039.9.4 Nature of the Facility ...................................................................39-4039.9.5 Sample Disposition Orders .........................................................39-40

39.10 Foster Care ................................................................................................39-41

39.11 Status Considerations ................................................................................39-41

39.12 EW Actions to Discontinue.........................................................................39-42

39.13 Summary Chart ........................................................................................39-42Comments for the above chart: .............................................39-43

40. Refugees/TCVAP ............................................................................................40-1

40.1 Medi-Cal Refugee Programs........................................................................40-1

40.2 Definitions ....................................................................................................40-140.2.1 Persons Identified by the Federal Government as Refugees .......40-140.2.2 Children of Refugees Identified by the Federal Government as

Refugees.......................................................................................40-240.2.3 Cuban/Haitian Entrants Identified as Refugees ............................40-340.2.4 Persons Not Identified by the Federal Government as Refugees.40-3

40.3 Medi-Cal Eligibility Period ...........................................................................40-440.3.1 Cash Based Medi-Cal and .......................................... RMA/EMA40-440.3.2 Refugee Medical Assistance (RMA)

Entrant Medical Assistance (EMA) ..............................................40-4Eligibility Criteria ......................................................................40-4Social Security Number Requirement ......................................40-5

40.4 Beginning Date of Aid of RMA/EMA Eligibility..............................................40-5

40.5 Eligibility Determination................................................................................40-740.5.1 Program Determination.................................................................40-740.5.2 Specific Considerations ................................................................40-840.5.3 Financial Requirements ................................................................40-8

Exempt Income and Property .................................................40-9Clarifications ..........................................................................40-10

40.5.4 Date of Application......................................................................40-12



40.5.5 Refugee Cash Assistance (RCA) Entrant Cash Assistance (ECA) ..................................................40-13

40.6 Alleged Disability ........................................................................................40-13

40.7 RMA/EMA Discontinuance .........................................................................40-14

40.8 Retroactive RMA/EMA Eligibility ................................................................40-15

40.9 Sponsor/VOLAG Contact ..........................................................................40-1740.9.1 Role of Resettlement Agency......................................................40-1740.9.2 Intake Procedure.........................................................................40-1740.9.3 Resettlement and Matching Grants............................................40-18

40.10 Lost Boys of Sudan ....................................................................................40-18

40.11 Victims of a Severe Form of Trafficking .....................................................40-1940.11.1 Definition .....................................................................................40-1940.11.2 Certification and Verification as a Victim of a Severe Form of

Trafficking....................................................................................40-1940.11.3 Eligibility Determination...............................................................40-2040.11.4 Eligibility Period...........................................................................40-2040.11.5 Family Members of Severe Trafficking Victims ...........................40-21

Eligibility Determination ..........................................................40-21

40.12 Afghan and Iraqi Special Immigrants (SIs).................................................40-2240.12.1 RMA Period of Eligibility ..............................................................40-2240.12.2 Documentation Requirements.....................................................40-2240.12.3 Refugees Discontinued from SSI ................................................40-23

40.13 Tuberculosis (TB) Program ........................................................................40-23

40.14 Managed Care............................................................................................40-2440.14.1 Mental Health Managed Care Program.......................................40-24

40.15 Adjustment of Status for Refugees.............................................................40-24

40.16 Unaccompanied Refugee Minor................................................................40-2540.16.1 Eligibility ......................................................................................40-2540.16.2 Application...................................................................................40-2540.16.3 Eligibility Criteria..........................................................................40-2640.16.4 Duration of Eligibility [45 CFR 400.115 - 400.120] ......................40-2640.16.5 RRR ............................................................................................40-2740.16.6 Retro-MC.....................................................................................40-2740.16.7 Inter-County Transfers ................................................................40-27

41. State/County Administered Health Insurance Programs............................41-1



41.1 Access for Infants and Mothers Program (AIM) ...........................................41-1Overview ..................................................................................41-1Purpose ...................................................................................41-1Eligibility Criteria ......................................................................41-1

41.1.1 Income/Property Criteria ...............................................................41-2Limits .......................................................................................41-2Family size ...............................................................................41-2Total Family Income ................................................................41-2Examples .................................................................................41-3Verification of income ..............................................................41-3AIM Subscriber Contribution Chart ..........................................41-3Property ...................................................................................41-3

41.1.2 Subscriber Contribution ................................................................41-4Payments .................................................................................41-4Discount ...................................................................................41-4Mandatory Payment .................................................................41-4Penalty .....................................................................................41-4Second Payment .....................................................................41-4Discount ...................................................................................41-5

41.1.3 Care Providers/Covered Services.................................................41-5Participants ..............................................................................41-5Coverage .................................................................................41-5

41.1.4 Application Review........................................................................41-5Where Located ........................................................................41-5Section 1 ..................................................................................41-6Section 2 ..................................................................................41-6Section 3 ..................................................................................41-6Section 4 ..................................................................................41-7Section 5 ..................................................................................41-7Pregnancy Certification ............................................................41-7AIM Application Assistance Fee ..............................................41-7Checklist ..................................................................................41-7EW Notification ........................................................................41-8Mail To .....................................................................................41-8

41.2 Presumptive Eligibility for Pregnant Women (Proc 5M) .....................................................................................................41-941.2.1 Background...................................................................................41-9

Overview ..................................................................................41-941.2.2 Eligibility Criteria ...........................................................................41-9

Period of Eligibility .................................................................41-1041.2.3 PE Covered Services..................................................................41-1141.2.4 PE Enrollment .............................................................................41-11

PE Enrollment Forms .............................................................41-1141.2.5 PE Application Process for Medi-Cal ..........................................41-1241.2.6 Retroactive Coverage .................................................................41-14



41.2.7 Other ...........................................................................................41-14General Information ...............................................................41-14

41.3 Healthy Families Program (HFP) ...............................................................41-1541.3.1 Background .................................................................................41-1541.3.2 Effective Dates ............................................................................41-15

Transition Phases ..................................................................41-1541.3.3 Transition ....................................................................................41-16

Transition Aid Codes ..............................................................41-16Premiums ...............................................................................41-17

41.3.4 Medi-Cal Determinations.............................................................41-17Continuous Eligibility for Children (CEC) ...............................41-18

41.3.5 Transition Process ......................................................................41-1841.3.6 Informing Notices ........................................................................41-19

Welcome Packet ....................................................................41-19Beneficiary Identification Cards .............................................41-19

41.3.7 Single Point of Entry....................................................................41-20Accelerated Enrollment (AE) ..................................................41-20

41.4 Healthy Kids ...............................................................................................41-21Description .............................................................................41-21Purpose ..................................................................................41-21Scope of Coverage ................................................................41-21Eligibility Criteria ....................................................................41-22

41.5 Santa Clara County Children’s Health Initiative .........................................41-2241.5.1 Overview .....................................................................................41-22

Toll-Free Number ...................................................................41-2341.5.2 CHI Screening Process at Intake ................................................41-23

Role of the Application Assistor .............................................41-2341.5.3 CHI Screening Process at Redetermination................................41-25

Role of the Continuing EW .....................................................41-2541.5.4 CHI Review Process ...................................................................41-2641.5.5 Release of Information ................................................................41-2741.5.6 CHI Forms and Materials ............................................................41-27

41.6 Accelerated Enrollment (AE) for Children .................................................41-2841.6.1 Scope of Coverage and Aid Code...............................................41-2841.6.2 Children Ineligible for AE.............................................................41-2941.6.3 Informing Notices ........................................................................41-2941.6.4 AE MEDS Record .......................................................................41-2941.6.5 Reporting Approvals to MEDS ....................................................41-3041.6.6 Termination of AE .......................................................................41-30

41.7 CHDP Gateway Program ...........................................................................41-3141.7.1 Background .................................................................................41-3141.7.2 Pre-Enrollment by CHDP Providers ............................................41-31



41.8 Breast and Cervical Cancer Treatment Program (BCCTP) .......................41-3541.8.1 Every Woman Counts (EWC) Program.......................................41-36

Eligibility Criteria: ...................................................................41-3641.8.2 Health Insurance Coverage ........................................................41-3741.8.3 Federal BCCTP...........................................................................41-38

Ineligibility for federal BCCTP ................................................41-3841.8.4 State-Funded BCCTP .................................................................41-3841.8.5 Referrals to BCCTP ....................................................................41-3941.8.6 Referring Applicants....................................................................41-4041.8.7 Referring Beneficiaries................................................................41-4041.8.8 BCCTP Categories .....................................................................41-41

Categories for Females (only) Who Are Less Than 65 Years of Age 41-42Category for Males or Females ............................................41-43

41.8.9 Processing BCCTP Determinations............................................41-44Applicants with a DDSD Referral ...........................................41-44Applicants without a DDSD Referral ......................................41-45Denial NOA ............................................................................41-45Processing Chart ...................................................................41-45Medi-Cal Recipient Eligible for Federal BCCTP and NOA ....41-46Full Scope with a Disability Packet ........................................41-47Restricted Medi-Cal with a Disability Packet .........................41-47Disability Determination for Applicant or Recipient Approved Federal BCCTP .....................................................................41-47BCCTP Processing Chart for Medi-Cal Beneficiaries ............41-48

41.8.10 Medi-Cal Discontinuance NOA ...................................................41-49MC 351 and MC 239 A ..........................................................41-50

41.8.11 Retroactive Benefits ....................................................................41-5041.8.12 Annual Redetermination (RD) for BCCTP Eligibility....................41-5041.8.13 State Hearings and Appeals .......................................................41-5041.8.14 Managed Care for BCCTP Beneficiaries ....................................41-5141.8.15 Recipients Ineligible for BCCTP..................................................41-51

Time Frame ...........................................................................41-5241.8.16 Beneficiaries Ineligible for federal or state BCCTP.....................41-52

CalWIN Process ....................................................................41-54

41.9 Health Care Coverage Assistance Program ..............................................41-55Application: ............................................................................41-55Verifications: ..........................................................................41-56

41.9.1 Ability to Pay Determination Program .........................................41-5641.9.2 Valley Care .................................................................................41-5741.9.3 Discount Program .......................................................................41-5741.9.4 Waiver Program ..........................................................................41-5741.9.5 Inpatient Financial Services ........................................................41-58

42. State Waiver Programs and Limited Services ............................................42-1



42.1 Waiver Programs (Proc. 19-D] .....................................................................42-142.1.1 Background ...................................................................................42-142.1.2 Overview .......................................................................................42-142.1.3 DHS In-Home Operations (IHO)....................................................42-242.1.4 Early and Periodic, Screening, Diagnosis and Treatment (EPSDT)

Program ........................................................................................42-242.1.5 Personal Care Services Program (PCSP).....................................42-2

42.2 Department of Developmental Services - Home and Community-Based (DDS-HCBS) Waiver ....................................................................................42-342.2.1 Background ...................................................................................42-3

Benefits ....................................................................................42-4Requirements ...........................................................................42-4

42.2.2 Medi-Cal Eligibility .........................................................................42-6Application Referrals ................................................................42-6“Public Agency” Representative ...............................................42-6MFBU Determination ...............................................................42-7DDS-HCBS Aid Codes .............................................................42-7Reporting Responsibilities .......................................................42-7Budgeting Methodology ...........................................................42-7Retro Medi-Cal .........................................................................42-8

42.2.3 Procedure......................................................................................42-8DDS-HCBS Determination For a New Applicant .....................42-8DDS-HCBS Determination for a Currently Eligible Medi-Cal Recipient ...................................................................42-9Notices of Action (NOAs) .......................................................42-10Referring Agency ...................................................................42-10Release of Information ...........................................................42-10Redeterminations (RDs) ........................................................42-10Termination of DDS-HCBS Waiver ........................................42-11

42.3 Model Nursing Facility (Model-NF) Waiver.................................................42-11

42.4 Model IHO Waiver ......................................................................................42-11Requirements .........................................................................42-12

42.4.1 Medi-Cal IHO Waiver Inquiries....................................................42-1242.4.2 DHS In-Home Operations (IHO) - Initial Screening.....................42-13

When Medical Requirements are Met ....................................42-1342.4.3 EW - Medi-Cal Eligibility Determination.......................................42-13

Institutional Deeming .............................................................42-13MFBU Determination .............................................................42-13Medi-Cal IHO Waiver Aid Codes ...........................................42-14Reporting Responsibilities .....................................................42-14Budget Methodology ..............................................................42-14Medi-Cal IHO Waiver Approval and Beginning Date of Aid ...42-14Notice of Action Requirement ................................................42-15



Referring Agency ...................................................................42-15

42.5 Multipurpose Senior Service Program (MSSP) Waiver..............................42-1542.5.1 Benefits .......................................................................................42-1642.5.2 Eligibility Requirements...............................................................42-1642.5.3 Referring Agency ........................................................................42-17

Release of Information ...........................................................42-1742.5.4 Redeterminations (RD) ...............................................................42-1742.5.5 Termination of MSSP Waiver......................................................42-1742.5.6 Eligibility Determination...............................................................42-1842.5.7 MFBU Determination ..................................................................42-1942.5.8 MSSP Process............................................................................42-19

MSSP Determination For a New Applicant ............................42-19MSSP Determination for a Currently Eligible Medi-Cal Recipient ..42-20

42.5.9 MSSP Examples .........................................................................42-21Example 1 ..............................................................................42-21Example 2 ..............................................................................42-21Example 3 ..............................................................................42-21

42.6 Additional Waiver Programs.......................................................................42-2142.6.1 In-Home Medical Care Services (IHMC) Waiver.........................42-22

Eligibility Requirements .........................................................42-22Referring Agency ...................................................................42-22

42.6.2 Nursing Facility (NF) Services Waiver ........................................42-22Eligibility Requirements .........................................................42-23Referring Agency ...................................................................42-23

42.6.3 Acquired Immune Deficiency Syndrome (AIDS) Waiver .............42-23Eligibility Requirements .........................................................42-23Referring Agency ...................................................................42-24

42.7 Severely Impaired Working Individuals Program (Aid Code 8G) ............................................................................................42-2442.7.1 Background.................................................................................42-2442.7.2 Eligibility Requirements...............................................................42-24

Model Waiver Referral ...........................................................42-2542.7.3 Procedure ...................................................................................42-25

42.8 Limited Services Due to Program Abuse [Proc. 19-A] ...............................42-2542.8.1 Background.................................................................................42-2542.8.2 DHS Responsibility .....................................................................42-2642.8.3 County Responsibility .................................................................42-2642.8.4 Medi-Cal Benefits Issuances ......................................................42-27

42.9 Limited Services for MIAs in SNF/ICF [Proc. 19-C] ...................................42-2742.9.1 Background.................................................................................42-2742.9.2 County Responsibility .................................................................42-27



42.9.3 Medi-Cal Benefits ........................................................................42-2842.9.4 Retroactive Medi-Cal...................................................................42-2842.9.5 Undocumented Immigrants in LTC..............................................42-28

43. Special Treatment Programs.........................................................................43-1

43.1 General.........................................................................................................43-1

43.2 Referrals to VMC..........................................................................................43-1

43.3 Definitions.....................................................................................................43-243.3.1 Medi-Cal Special Treatment Program — ONLY Beneficiary.........43-243.3.2 Medi-Cal Special Treatment Program — SUPPLEMENT

Beneficiary ....................................................................................43-243.3.3 Dialysis ..........................................................................................43-243.3.4 Parenteral Hyperalimentation .......................................................43-343.3.5 Annual Net Worth..........................................................................43-343.3.6 Percentage Obligation...................................................................43-3

43.4 Eligibility Requirements ................................................................................43-443.4.1 Reporting Responsibilities.............................................................43-443.4.2 Medicare Application Requirements..............................................43-5

MSTP for Dialysis Coverage ....................................................43-5MSTP for TPN Coverage .........................................................43-5Follow-Up on Medicare Applications ........................................43-6Eligibility for the Medicare Dialysis Program ............................43-6Things to Remember ...............................................................43-7

43.5 Aid Codes.....................................................................................................43-7

43.6 Annual Net Worth [50825] ............................................................................43-743.6.1 Determination of Annual Net Worth ..............................................43-8

Whose Property/Income to Include ..........................................43-8Excluded/Exempt Property ......................................................43-8

43.7 Determination of Percentage Obligation [50827] .........................................43-943.7.1 Example: MSTP - Only..................................................................43-9

43.8 Share-of-Cost MSTP-Supplement Program [50831]..................................43-10

43.9 MC 176-D Instructions for Completion .......................................................43-1143.9.1 Part I: Identification .....................................................................43-1143.9.2 Part II: Eligibility Requirements - Summary.................................43-1143.9.3 Part III: Annual Net Worth Computations ....................................43-11

Percentage Obligation Determination — Part III, Section D .43-12

43.10 Establishing a MEDS Record .....................................................................43-12



43.11 Status Reports ...........................................................................................43-12

43.12 Annual Redetermination.............................................................................43-13

43.13 Notice of Action ..........................................................................................43-13

43.14 TB Program................................................................................................43-1343.14.1 Background.................................................................................43-1343.14.2 Program Benefits ........................................................................43-1343.14.3 Covered Services........................................................................43-1443.14.4 Aid Code .....................................................................................43-1443.14.5 Effective Date..............................................................................43-1443.14.6 Who Is Eligible ............................................................................43-14

General ..................................................................................43-14Dually Eligible ........................................................................43-15

43.14.7 Role of TB Providers...................................................................43-15

43.15 TB Eligibility Criteria ...................................................................................43-1643.15.1 General .......................................................................................43-1643.15.2 Income Limit................................................................................43-1643.15.3 Resource Limit ............................................................................43-1643.15.4 Citizen/Alien Status.....................................................................43-1743.15.5 Undocumented Persons .............................................................43-1743.15.6 Certification of TB Infection.........................................................43-1743.15.7 Other Requirements....................................................................43-1743.15.8 TB Child ......................................................................................43-1843.15.9 “Ineligible Spouse/Child” .............................................................43-1843.15.10 Married Person ...........................................................................43-19

43.16 TB Application Process ..............................................................................43-1943.16.1 Introduction .................................................................................43-1943.16.2 TB Application Packet .................................................................43-1943.16.3 TB Application (MC 274TB) ........................................................43-2043.16.4 TB Applications Initiated by Clinics .............................................43-2043.16.5 Homeless Applicant ....................................................................43-2143.16.6 Persons in LTC ...........................................................................43-2143.16.7 Plastic BIC ..................................................................................43-2143.16.8 TB NOAs.....................................................................................43-2143.16.9 Retroactive Benefits ....................................................................43-22

43.17 TB Property Determination and Examples.................................................43-2243.17.1 TB Property Limit ........................................................................43-2243.17.2 MC 278TB/ MC 279TB................................................................43-2243.17.3 Single Person..............................................................................43-2343.17.4 Married Couple ...........................................................................43-2343.17.5 Child, Under 18 ...........................................................................43-2343.17.6 Parental Deeming .......................................................................43-23



43.17.7 MC 279TB, Instructions, Child ....................................................43-24

43.18 TB Income Determination & Budgeting Examples .....................................43-2543.18.1 TB Income Standards .................................................................43-2543.18.2 FBR Rates/SSI Standard Allocation............................................43-2543.18.3 Financial Eligibility .......................................................................43-2543.18.4 Deemed Income Rules................................................................43-2643.18.5 Child's Income.............................................................................43-2743.18.6 MC 282TB, Instructions...............................................................43-2843.18.7 MC 280TB, Instructions...............................................................43-29

43.19 TB Continuing Activities .............................................................................43-3143.19.1 Midyear Status Reports (MSR) ...................................................43-3143.19.2 Redetermination..........................................................................43-3143.19.3 Active Cases ...............................................................................43-3143.19.4 Ineligible Persons........................................................................43-31


45. Diligent Search................................................................................................45-1

45.1 Diligent Search .............................................................................................45-145.1.1 Referral to Public Guardian or Conservator ..................................45-145.1.2 Disability Determination Referral...................................................45-145.1.3 Diligent Search..............................................................................45-1

Persons Without Identification .................................................45-2Persons With Identification ......................................................45-2

45.1.4 Case Processing ...........................................................................45-245.1.5 Name.............................................................................................45-345.1.6 Aid Code .......................................................................................45-345.1.7 Birth Date ......................................................................................45-345.1.8 Social Security Number.................................................................45-345.1.9 Health Insurance Claim Number ...................................................45-445.1.10 Address .........................................................................................45-4

45.2 .....................................................................................................................45-4

46. Other Health Coverage (OHC) ......................................................................46-1

46.1 Introduction [50761]......................................................................................46-146.1.1 Background ...................................................................................46-146.1.2 Definition .......................................................................................46-1

46.2 Client Responsibility .....................................................................................46-146.2.1 Reporting.......................................................................................46-146.2.2 Fraud Referrals .............................................................................46-2



46.3 EW Responsibility ........................................................................................46-346.3.1 Informing .......................................................................................46-346.3.2 Identification..................................................................................46-346.3.3 EW Actions ...................................................................................46-446.3.4 Good Cause..................................................................................46-546.3.5 Reporting OHC Changes or New Policy .......................................46-646.3.6 Removing OHC.............................................................................46-8

Verification ...............................................................................46-8OHC Termination/Removal Process ........................................46-9

46.4 Insurance Policies Requiring OHC Identification .......................................46-10Cancer Only ...........................................................................46-10TRI-CARE (formerly known as CHAMPUS) ..........................46-10Dental Only ............................................................................46-10Employment-Related .............................................................46-10ERISA (Employee Retirement Income Security Act) .............46-10Group Health .........................................................................46-10Health ....................................................................................46-11Hospital ..................................................................................46-11Indemnity ...............................................................................46-11Long-Term Care ....................................................................46-11Major Medical ........................................................................46-11Medical Support .....................................................................46-11Medicare Supplemental .........................................................46-11PHP/HMO ..............................................................................46-11Prescription ............................................................................46-12Student Health .......................................................................46-12Surgical ..................................................................................46-12Vision .....................................................................................46-12

46.5 COBRA ......................................................................................................46-1246.5.1 Continuation of Benefits ..............................................................46-1246.5.2 Employers Affected.....................................................................46-1346.5.3 Notification Requirements...........................................................46-1346.5.4 Payment of Premium ..................................................................46-1346.5.5 Termination of Coverage ............................................................46-13

46.6 Insurances Not Included as OHC...............................................................46-1346.6.1 Unavailable .................................................................................46-1346.6.2 Other ...........................................................................................46-14

46.7 Health Insurance Premium Payment (HIPP) Program...............................46-1546.7.1 Definition .....................................................................................46-1546.7.2 HIPP Qualifications .....................................................................46-1546.7.3 EW Action ...................................................................................46-16

Completing the online application ..........................................46-16



46.7.4 DHCS Responsibility ...................................................................46-1846.7.5 HIPP Approved ...........................................................................46-1846.7.6 Client Disenrolls from OHC voluntarily ........................................46-18

46.8 HIPP Questions and Answers ....................................................................46-1946.8.1 Referral Process .........................................................................46-1946.8.2 High Cost Medical Condition.......................................................46-1946.8.3 Approval ......................................................................................46-1946.8.4 Past Due Premiums ....................................................................46-2046.8.5 Non-Medi-Cal Family Member ....................................................46-2046.8.6 Requirement to Apply..................................................................46-2046.8.7 Insurance Lapsed........................................................................46-20

46.9 OHC Identification by DHCS ......................................................................46-2146.9.1 DHCS ..........................................................................................46-2146.9.2 Discrepancies..............................................................................46-21

46.10 OHC Billing Methods ..................................................................................46-2146.10.1 General .......................................................................................46-2146.10.2 Cost Avoidance ...........................................................................46-2246.10.3 PHP, HMO, Triwest .....................................................................46-22

46.11 Cost Avoidance Coverage..........................................................................46-2346.11.1 Identification ................................................................................46-2346.11.2 DHCS Responsibility ...................................................................46-2346.11.3 EW Responsibility .......................................................................46-2346.11.4 Recording OHC in CalWIN and MEDS .......................................46-2346.11.5 Effective Date of Cost Avoidance................................................46-24

46.12 OHC Information on Medi-Cal Records.....................................................46-2446.12.1 OHC/HIAR SCREEN on MEDS ..................................................46-2446.12.2 Providers .....................................................................................46-2546.12.3 Information Lacking.....................................................................46-2546.12.4 EW Responsibility .......................................................................46-2546.12.5 Verification ..................................................................................46-2646.12.6 Temporary OHC Removal...........................................................46-27

46.13 Removal of OHC Codes for Victims of Domestic Violence ........................46-2746.13.1 Problem.......................................................................................46-2746.13.2 EW Responsibility .......................................................................46-27

Removing the OHC Code from MEDS ...................................46-28Removing OHC Information from CalWIN .............................46-28

46.14 OHC for Foster Care/Adoption Assistance Children ..................................46-2946.14.1 Problem.......................................................................................46-2946.14.2 OHC Coding Changes ................................................................46-2946.14.3 SSI Children ................................................................................46-29



46.14.4 Recording OHC in CalWIN .........................................................46-30

46.15 Repayment for Medical Services ...............................................................46-3046.15.1 Rule.............................................................................................46-3046.15.2 Endorse Checks..........................................................................46-3046.15.3 Provider Overpayments (OP) Program......................................46-3146.15.4 DHCS Recovery..........................................................................46-31

47. Third Party Liability (TPL)..............................................................................47-1

47.1 Applicant/Client Responsibility [50771] ........................................................47-147.1.1 Assignment ...................................................................................47-147.1.2 Potential Third Party Liability Claims.............................................47-147.1.3 Notification of Third Party Liability.................................................47-1

47.2 EW Responsibility ........................................................................................47-247.2.1 Workers’ Compensation................................................................47-247.2.2 Procedure .....................................................................................47-2

47.3 When DHCS Receives a Third Party Payment ............................................47-3

48. In-Home Supportive Services (IHSS)............................................................48-1

48.1 IHSS Programs ............................................................................................48-148.1.1 IHSS Residual...............................................................................48-148.1.2 Personal Care Services Program (PCSP) ....................................48-248.1.3 IHSS Plus Waiver .........................................................................48-248.1.4 Aid Codes .....................................................................................48-2

48.2 Spenddown ..................................................................................................48-348.2.1 CMIPS and MEDS Interface .........................................................48-3

MEDS Reports .........................................................................48-4

48.3 Medi-Cal Rules.............................................................................................48-548.3.1 Share of Cost (SOC).....................................................................48-6

Reimbursement Process: ........................................................48-6

48.4 Inter-County Transfer (ICT)..........................................................................48-6

48.5 Special IHSS Deduction...............................................................................48-748.5.1 Who Is Eligible for this Special IHSS Deduction? .........................48-748.5.2 In-Home Supportive Services Payment for Intake ........................48-8

Physician's Statement .............................................................48-8IHSS Assessment and Cost Verification ..................................48-9

48.5.3 Allowable Deduction and Verification............................................48-948.5.4 Eligibility Requirements for Continuing .......................................48-1048.5.5 Verification Received at a Later Time .........................................48-10



48.5.6 Annual Requirements for Reassessment....................................48-10

49. Benefits Identification Cards, Overpayments, Billing & LOA (BOBLOA) 49-1

49.1 Medi-Cal Identification Cards .......................................................................49-149.1.1 Background ...................................................................................49-1

The Benefits Identification Card (BIC) .....................................49-2The Paper Identification Card ..................................................49-2

49.1.2 California Eligibility Verification System and Claim Management System (CA-EV/CMS)...................................................................49-2

Medi-Cal Eligibility Verification .................................................49-349.1.3 BIC Use/Authorization [50731, 50733, 50735] ..........................49-4

Use ...........................................................................................49-4Authorization for use ................................................................49-4

49.2 Medi-Cal Identification Card Format.............................................................49-549.2.1 BIC format .....................................................................................49-5

Front of the BIC ........................................................................49-6Back of the BIC ........................................................................49-6Signature Requirements ..........................................................49-6

49.2.2 The Paper Card.............................................................................49-749.2.3 Client Index Number .....................................................................49-7

49.3 MEDI Reserve System .................................................................................49-7

49.4 Non SSI/SSP Medi-Cal Identification Card Issuance ...................................49-849.4.1 BIC issuance for Non-SSI/SSP Recipients ...................................49-849.4.2 Paper Card Issuance for Non-SSI/SSP Recipients.......................49-9

49.5 Health Access Program Card (HAP) ............................................................49-949.5.1 Family Planning, Access, Care and Treatment Program

(Family PACT)...............................................................................49-9

49.6 Non SSI/SSP Medi-Cal Identification Card Replacement ..........................49-1049.6.1 BIC Replacement ........................................................................49-1049.6.2 Replacement of Paper Cards......................................................49-10

49.7 SSI/SSP Medi-Cal Identification Cards ......................................................49-1149.7.1 SSI/SSP Initial BIC Issuance ......................................................49-1149.7.2 SSI/SSP BIC Replacement .........................................................49-12

49.8 Letter of Authorization ................................................................................49-13Administrative Error ...............................................................49-14

49.8.1 Non SSI/SSP Letter of Authorization (LOA) Process..................49-1549.8.2 SSI/SSP Letter of Authorization (LOA) Process..........................49-16

49.9 Share-of-Cost Record System ..................................................................49-1849.9.1 Share of Cost Online Record ......................................................49-18



SOCO Transactions ...............................................................49-18Share-of-Cost Reversal .........................................................49-19

49.10 Service Restrictions for Medi-Cal Abuse/Codes and Messages................49-19

49.11 BIC/CIN Information on MEDS Screens ....................................................49-2049.11.1 INQM and INQ1 Screens ............................................................49-20

BIC Issue Date .......................................................................49-20Paper ID Card Issue Date ......................................................49-20

49.11.2 MOPI Screen ..............................................................................49-2149.11.3 SOCR Screen .............................................................................49-21

49.12 Copayment.................................................................................................49-21

49.13 Disposition of Returned Medi-Cal Cards....................................................49-22Returned (Undeliverable) Cards ............................................49-22EW Responsibilities ...............................................................49-23

49.14 Release of Medi-Cal Eligibility Information to Providers ............................49-2349.14.1 Medi-Cal Eligibility Data System (MEDS) ...................................49-2449.14.2 Information Which May be Released to a Provider....................49-2449.14.3 Ineligible Individual......................................................................49-2549.14.4 Request for Medi-Cal Eligibility Information for a

Deceased Individual....................................................................49-2549.14.5 Release of Information on an Ineligible Person ..........................49-25

49.15 Out-of-State Billing ....................................................................................49-2649.15.1 Medi-Cal Card Use .....................................................................49-2649.15.2 Prior Authorization ......................................................................49-2649.15.3 Claims Procedure .......................................................................49-27

49.16 Overpayement Overview...........................................................................49-2749.16.1 Definition of Potential Overpayments..........................................49-2849.16.2 Causes of Potential Overpayments ............................................49-2949.16.3 No Overpayment Exists ..............................................................49-29

49.17 Overpayment Rules ...................................................................................49-3049.17.1 Overpayment Responsibility in Cases with

Authorized Representative..........................................................49-31

49.18 Determining Overpayment Period..............................................................49-3249.18.1 Example ......................................................................................49-32

49.19 Determining Usage ....................................................................................49-33

49.20 Types of Potential Medi-Cal Overpayments...............................................49-3349.20.1 Potential Overpayment Due to Increased SOC ..........................49-3449.20.2 Potential Overpayment Due to Excess Property.........................49-34



49.20.3 Potential Overpayment Due to Total Ineligibility..........................49-3449.20.4 Potential Overpayments Due to Unreported

Other Health Coverage (OHC)....................................................49-3449.20.5 CalWORKs Ineligibility ................................................................49-3449.20.6 Potential Overpayments Due to CalWORKs Fraud.....................49-35

49.21 Calculating the Overpayment Amount........................................................49-3549.21.1 Potential Overpayments Due to Increased (SOC) ......................49-3549.21.2 Potential Overpayments Due to Excess Property .......................49-35

Computation [50423] ..............................................................49-3649.21.3 Potential Overpayment Due to Total Ineligibility..........................49-3649.21.4 Potential Overpayments Due to Unreported

Other Health Coverage (OHC)....................................................49-3749.21.5 CalWORKs Ineligibility - Excess Property ...................................49-3749.21.6 CalWORKs Ineligibility - All Other Reasons

(Property Within Medi-Cal Reserve Limits) .................................49-3749.21.7 Required Action for Incorrect Income or MFBU Situations..........49-38

49.22 CalWIN .......................................................................................................49-39Re-evaluation of Share of Cost or Eligibility ...........................49-40Recording of Potential Overpayment to DHS in CalWIN .......49-40

49.23 Calculating Potential Overpayment Sneede Case .....................................49-40

49.24 Overpayment Referral Procedures.............................................................49-4049.24.1 Where to Send Referrals.............................................................49-4149.24.2 Required Forms For Overpayment Referral Packets ..................49-41

MC 609 “Confidential Medi-Cal Complaint Report” ................49-41MC 224A “Medi-Cal Potential Overpayment Reporting Worksheet - Income Or Other Health Coverage” ...................49-42MC 224B “Medi-Cal Potential Overpayment Reporting Worksheet - Property” ............................................................49-42“Statement of Facts” & Supplements .....................................49-42MC 219 “Medi-Cal Rights and Responsibilities Checklist”, SAWS 2A “Rights & Responsibilities and Other Important Information” ............................................................................49-42Other ......................................................................................49-43

49.25 Forms and Instructions for Completion .....................................................49-4349.25.1 “Confidential Medi-Cal Complaint Report” (MC 609)...................49-4349.25.2 “Medi-Cal Potential Overpayment Reporting

Work Sheet - Income or Other Health Coverage” (MC 224 A)..................................................................................49-44

Section 1 - Case Information .................................................49-44Section II - Possession of Other Health Coverage ................49-45Section III--Income Overpayment Computation .....................49-45Section IV - County Worker Comments .................................49-45



Section V - County Worker Completing the Form ..................49-4649.25.3 “Medi-Cal Potential Overpayment Reporting

Work Sheet - Property” (MC 224 B) ............................................49-46Section 1 - Case Information .................................................49-46Section II - Property ...............................................................49-46Section III - Overpayment Computation .................................49-46Section IV - Summary ............................................................49-46Section V - County Worker Comments ..................................49-47Section VI - County Worker Completing the Form .................49-47

49.26 Overpayment Examples...........................................................................49-4749.26.1 Potential Overpayment, Income..................................................49-4749.26.2 Potential Overpayment, Property................................................49-48

49.27 SSI Advocacy - Letters of Authorization.....................................................49-48

50. Court Orders ...................................................................................................50-1

50.1 Beltran v Rank..............................................................................................50-150.1.1 Issue .............................................................................................50-150.1.2 Decision ........................................................................................50-1

50.2 Craig v Bontá ...............................................................................................50-150.2.1 Issue .............................................................................................50-150.2.2 Decision ........................................................................................50-150.2.3 SB 87 Redetermination Process...................................................50-2

Step One: Ex parte Review .....................................................50-2Step Two: Direct Contact .........................................................50-2Step Three: Use of the “Request for Information” Form (MC 355) .50-3

50.2.4 MC 355 Timelines .........................................................................50-350.2.5 When an SB 87 Redetermination is Not Necessary .....................50-450.2.6 Craig Redetermination Process ....................................................50-450.2.7 DDSD Disability Referral Packets .................................................50-650.2.8 Aid Codes Under State Control.....................................................50-750.2.9 Exception Eligibles Report ............................................................50-750.2.10 Identification of Craig Clients Groups by Codes ...........................50-7

The No Longer Disabled Group ...............................................50-8Disabled Adult Child (DAC) Group ..........................................50-8Disabled Adult Widow(er)s Group ...........................................50-9Pickle Group ............................................................................50-9All Other Discontinued from SSI/SSP Benefits ........................50-9

50.2.11 Alleged Disability...........................................................................50-950.2.12 ICTs and Craig Beneficiaries ........................................................50-950.2.13 CEC and Craig Children .............................................................50-1150.2.14 Annual Redetermination .............................................................50-12



50.2.15 IHSS and Craig Clients ...............................................................50-1250.2.16 Forms ..........................................................................................50-13

Medi-Cal Informational Craig Packet .....................................50-1350.2.17 Questions and Answers ..............................................................50-13

50.3 Crawford v Rank.........................................................................................50-1450.3.1 Issue............................................................................................50-1450.3.2 Decision ......................................................................................50-15

50.4 Edwards v Kizer (AKA Edwards v Myers) ..................................................50-1550.4.1 Issue............................................................................................50-1550.4.2 Decision ......................................................................................50-15

50.5 Gibbins v Rank ...........................................................................................50-1650.5.1 Issue............................................................................................50-1650.5.2 Decision ......................................................................................50-16

50.6 Ibarra v Dawson .........................................................................................50-1650.6.1 Issue............................................................................................50-1650.6.2 Effective Date..............................................................................50-16

50.7 Johnson v Rank..........................................................................................50-1750.7.1 Issue............................................................................................50-1750.7.2 Decision ......................................................................................50-17

50.8 King v McMahon.........................................................................................50-1750.8.1 Issue............................................................................................50-1750.8.2 Treatment of Payments...............................................................50-18

50.9 Lomeli v. Shewry ........................................................................................50-1850.9.1 Issue............................................................................................50-1850.9.2 Settlement ...................................................................................50-1850.9.3 Informing Notices ........................................................................50-1850.9.4 MC 19A .......................................................................................50-1850.9.5 MC 19..........................................................................................50-19

50.10 Ramos v Myers ..........................................................................................50-1950.10.1 Issue............................................................................................50-19

50.11 Court Orders: Lynch v. Rank - Pickle Amendment .....................................................................................50-20

50.12 Overview ....................................................................................................50-2050.12.1 Background .................................................................................50-2050.12.2 SSI/SSP Standards and Regulations..........................................50-2150.12.3 Eligibility Determination Process.................................................50-2150.12.4 Pickle Forms ...............................................................................50-2250.12.5 Pickle Aid Codes .........................................................................50-23



50.13 Definitions ..................................................................................................50-2350.13.1 Actual Value (AV)........................................................................50-2350.13.2 Automobile ..................................................................................50-2450.13.3 Burial Funds ...............................................................................50-2450.13.4 Cash Surrender Value (CSV)......................................................50-2450.13.5 Child............................................................................................50-2450.13.6 Couple.........................................................................................50-2550.13.7 Current Market Value (CMV) or Current Market Rental

Value (CMRV) ............................................................................50-2550.13.8 Dependent Relative ...................................................................50-2550.13.9 Discounted Amount.....................................................................50-2650.13.10 Equity Value (EV) .......................................................................50-2650.13.11 Excludable Equity Value .............................................................50-2650.13.12 Home .........................................................................................50-2650.13.13 Household Expenses .................................................................50-2650.13.14 Immediate Family .......................................................................50-2750.13.15 Independent Living Arrangement ................................................50-2750.13.16 Ineligible Spouse.........................................................................50-2750.13.17 In-Kind Support and Maintenance (ISM) ....................................50-2750.13.18 Institutionalization ......................................................................50-2850.13.19 Items of Unusual Value...............................................................50-2850.13.20 Life Estate and Remainder Interest ...........................................50-2850.13.21 Liquid Resources .......................................................................50-2950.13.22 Nonliquid Resources...................................................................50-2950.13.23 Non-Medical Out of Home Care (NMOHC).................................50-2950.13.24 Parent ........................................................................................50-2950.13.25 Presumed Maximum Value (PMV) .............................................50-2950.13.26 Principal Place of Residence ......................................................50-3050.13.27 Property (Real or Personal), Essential to Self-Support...............50-3150.13.28 Rebutting the PMV......................................................................50-3150.13.29 Recreational Vehicle (RV)...........................................................50-3250.13.30 Rent-Free Shelter ......................................................................50-3250.13.31 Resources ..................................................................................50-3250.13.32 Sharing .......................................................................................50-3250.13.33 Successful Rebuttal ....................................................................50-3350.13.34 Value of the One-Third Reduction (VTR) ...................................50-33

50.14 Pickle Screening Process ..........................................................................50-3350.14.1 Who Must be Screened ..............................................................50-33

Exceptions .............................................................................50-3350.14.2 When to Screen ..........................................................................50-3450.14.3 How to Screen ............................................................................50-34

Part I - Screening Process: ....................................................50-3450.14.4 Verification of SSI/SSP Termination Date...................................50-36

50.15 Title II Disregard Computation ...................................................................50-37



50.15.1 Disregard Computation for an Individual .....................................50-37Part II - Disregard Computation .............................................50-38

50.15.2 Disregard Computation for a Couple...........................................50-38Example 1: .............................................................................50-38Example 2: .............................................................................50-38

50.16 Treatment of Income ..................................................................................50-3950.16.1 Earned Income............................................................................50-3950.16.2 Unearned Income........................................................................50-4050.16.3 Excluded Income.........................................................................50-41

50.17 Financial Eligibility ......................................................................................50-4350.17.1 When to Complete the Financial Eligibility Test ..........................50-4350.17.2 Needs Test ..................................................................................50-4450.17.3 Financial Eligibility Worksheet.....................................................50-45

Potential Pickle Eligible Individual ..........................................50-45Couples, Both Potential Pickle Persons, e.g., both have passed the screening test. .....................................................50-45Couples, Only One Potential Pickle Eligible, e.g., only one spouse passed the screening test. ........................................50-46Establishing Medi-Cal Eligibility for a Pickle Person's Family. ........50-47

50.18 In-Kind Support and Maintenance (ISM) ....................................................50-4850.18.1 Definition .....................................................................................50-4850.18.2 VTR - Value of One Third Reduction ..........................................50-48

Definition ................................................................................50-48When to Use VTR ..................................................................50-48Do NOT apply VTR if the Pickle client: ..................................50-49SSI/SSP Payment Levels ......................................................50-49

50.18.3 PMV - Presumed Maximum Value ..............................................50-49Definition ................................................................................50-49When to Apply the PMV .........................................................50-49

50.18.4 The DHS 7044, Statement of Living Arrangement ......................50-5050.18.5 Rebutting the PMV ......................................................................50-5050.18.6 Examples of VTR and PMV: .......................................................50-5050.18.7 Sharing........................................................................................50-5150.18.8 ISM Values..................................................................................50-5150.18.9 Excluded Types of ISM ...............................................................50-52

50.19 Resource Determination.............................................................................50-5350.19.1 Resource Limits ..........................................................................50-5450.19.2 Determining Value of a Resource ...............................................50-5450.19.3 Resource Limits for Couples .......................................................50-54

Both spouses potentially Pickle eligible: ................................50-54Ineligible spouse, income deemed: ........................................50-54



Ineligible spouse, income not deemed: .................................50-5450.19.4 Excess Resources ......................................................................50-5550.19.5 SSI Treatment of Resources.......................................................50-55

50.20 Pickle Eligible Child....................................................................................50-6050.20.1 Title II Disregard Computation ....................................................50-6050.20.2 Needs Test..................................................................................50-6050.20.3 Financial Eligibility.......................................................................50-6050.20.4 Resource Eligibility......................................................................50-60

Examples: ..............................................................................50-6150.20.5 Financial Eligibility Worksheet (DHS 7019) Instructions .............50-61

50.21 COBRA - Widow Pickle..............................................................................50-6350.21.1 Background.................................................................................50-6350.21.2 Widow Pickle Screening Test .....................................................50-63

50.22 Disabled Widow(er)s ..................................................................................50-6450.22.1 Background.................................................................................50-6450.22.2 Definitions ...................................................................................50-6450.22.3 DHCS Actions .............................................................................50-6450.22.4 DHS 7089, Screening Worksheet ...............................................50-6450.22.5 Criteria ........................................................................................50-6550.22.6 Verification Requirements...........................................................50-6550.22.7 Budgeting....................................................................................50-6650.22.8 Annual Redetermination (RD).....................................................50-6650.22.9 Ineligibility ...................................................................................50-66

50.23 Disabled Adult Child (DAC)........................................................................50-6750.23.1 Background.................................................................................50-6750.23.2 DAC Screening Test ...................................................................50-6750.23.3 DHS Actions................................................................................50-6850.23.4 Budgeting....................................................................................50-6850.23.5 Verification ..................................................................................50-6850.23.6 Aid Codes ...................................................................................50-69

50.24 Persons Who Were Pickle (or IHSS) Eligible in the Month Prior to SSI/SSP Reductions.....................................................50-6950.24.1 Background.................................................................................50-69

1993 SSP Reduction .............................................................50-691994 SSP Reduction .............................................................50-691995 SSP Reduction .............................................................50-69Procedure, 8-93/8-94 SSP Reduction ...................................50-70Procedure, 12/95 SSP Reduction ..........................................50-71Charts ....................................................................................50-71Pickle Eligible .........................................................................50-71Additional Clarifications .........................................................50-72Exception ...............................................................................50-72



Pickle Ineligible ......................................................................50-7250.24.2 SSI/SSP Payment Standards......................................................50-7250.24.3 Annual Redeterminations............................................................50-73

50.25 Instructions, DHS 7021, Financial Eligibility Worksheet .............................50-7350.25.1 PART A. Needs Test ...................................................................50-7450.25.2 Part B. Ineligible Spouse's Unearned Income.............................50-7450.25.3 Part C. Ineligible Spouse's Earned Income.................................50-7550.25.4 Part D. Ineligible Spouse's Total Income After Allocations .........50-7550.25.5 Part E. Combined Income ...........................................................50-7650.25.6 Part F. Pickle Eligibility Calculation .............................................50-77

50.26 Instructions: DHS 7037, Pickle Resource Worksheet .......................................................................50-78

50.27 Annual Pickle Review Requirements .........................................................50-79

50.28 Pickle Tickler System .................................................................................50-7950.28.1 Overview .....................................................................................50-7950.28.2 Coding Requirements .................................................................50-8050.28.3 MEDS Coding Requirements ......................................................50-81

Persons Discontinued from SSI/SSP after 1/1/87 ..................50-81Persons Discontinued from SSI/SSP after 7/1/03 ..................50-81Recording Potential Pickle Eligibles on MEDS ......................50-81Changing/Correcting Potential Pickle Eligibility on MEDS .....50-82

50.28.4 Pickle Tickler Process .................................................................50-82Pickle Tickler Report ..............................................................50-82Stuffers ...................................................................................50-83Approvals ...............................................................................50-83Ineligibility ..............................................................................50-83

50.29 Court Orders: Reese through Hunt ............................................................50-84

50.30 Reese v Kizer ............................................................................................50-8450.30.1 Issue............................................................................................50-8450.30.2 Decision ......................................................................................50-84

50.31 Saldivar v McMahon ..................................................................................50-8450.31.1 Issue............................................................................................50-8450.31.2 Decision ......................................................................................50-85

50.32 Ball v Swoap ..............................................................................................50-8550.32.1 Issue............................................................................................50-8550.32.2 Decision ......................................................................................50-8550.32.3 Treatment of Payments...............................................................50-85

50.33 Disabled Rights Union v Kizer ...................................................................50-8550.33.1 Issue............................................................................................50-85



50.33.2 Effective Date..............................................................................50-86

50.34 LTC Prejudice Cases .................................................................................50-8650.34.1 Issue ...........................................................................................50-86

50.35 Hunt v Kizer ...............................................................................................50-8750.35.1 Issue ...........................................................................................50-8750.35.2 Decision ......................................................................................50-8750.35.3 EW Instructions...........................................................................50-87

50.36 Court Orders: Sneede v Kizer ....................................................................50-8750.36.1 Background.................................................................................50-8750.36.2 Definition “Sneede Case” ............................................................50-8850.36.3 Not Optional ................................................................................50-8850.36.4 Examples ....................................................................................50-89

Child with separate income ....................................................50-89Stepparent case .....................................................................50-89Nonparent Caretaker Relative ...............................................50-89

50.36.5 Separate Determinations ............................................................50-8950.36.6 Denial or Discontinuance of Sneede...........................................50-9050.36.7 General Procedures....................................................................50-9150.36.8 Implementation Date...................................................................50-92

50.37 Sneede Screening......................................................................................50-9250.37.1 Property ......................................................................................50-9250.37.2 Income ........................................................................................50-93

50.38 Responsible Relative Determination ..........................................................50-9350.38.1 MC 175-2 ....................................................................................50-93

50.39 Income and Property Allocations, General.................................................50-9450.39.1 General Allocation Rule ..............................................................50-9450.39.2 Property Allocation Rule .............................................................50-9450.39.3 Income Allocation Rule ...............................................................50-9450.39.4 Property and Income...................................................................50-9550.39.5 Allocations Not Allowed ..............................................................50-9550.39.6 Allocation Example .....................................................................50-9550.39.7 Property/Income are Separate....................................................50-9650.39.8 Treatment of Children .................................................................50-96

50.40 Mini Budget Unit Determination .................................................................50-9750.40.1 Definition .....................................................................................50-9750.40.2 Property/Income MBUs are Separate .........................................50-9750.40.3 Rules for All Cases .....................................................................50-9850.40.4 Specific MBU Determinations .....................................................50-98

Married Couple and Mutual Children (No Stepchildren) ........50-98Married Spouses (Stepparent),



Mutual and Separate Children ...............................................50-99Married Parents, Only the Separate Children of One Parent Want Medi-Cal ...50-99Single Parent, Children ........................................................50-100Unmarried Parents, Mutual and Separate Children .............50-100Minor Mother With Child(ren), Living With Her Parent(s) .....50-101

50.40.5 Parent(s)' MBU..........................................................................50-10150.40.6 Child(ren)s' MBU.......................................................................50-10150.40.7 Non-Parent Caretaker Relative Households .............................50-102

Linkage Rules ......................................................................50-102MBU Determinations ............................................................50-102

50.40.8 MC 175-4 ..................................................................................50-103

50.41 Maintenance Need Income Levels and Property Limits ...........................50-10450.41.1 General .....................................................................................50-10450.41.2 Full Amount ...............................................................................50-10450.41.3 Prorated Amount .......................................................................50-10550.41.4 Formula .....................................................................................50-10550.41.5 Prorated Maintenance Need Income Levels and Property Limits ........

50-106

50.42 Property Determination ............................................................................50-10650.42.1 General .....................................................................................50-10650.42.2 Property Allocations ..................................................................50-106

Married Couple With Only Mutual Children ..........................50-107Stepparent Household .........................................................50-107Unmarried Couple With Mutual Children .............................50-107

50.42.3 When Only One Property Exemption Applies ...........................50-10750.42.4 Exemptions for Unmarried Couples ..........................................50-10850.42.5 Exemption for Single/Married Parent(s) ....................................50-10850.42.6 Exemptions for Other Caretaker Relative..................................50-10850.42.7 Changing Exemptions ...............................................................50-10850.42.8 Jointly Held Assets ....................................................................50-109

Example 1: ...........................................................................50-109Example 2: ...........................................................................50-109

50.42.9 Procedure..................................................................................50-110Example 1 ............................................................................50-110Example 2 ............................................................................50-111

50.43 Income Determination ..............................................................................50-11250.43.1 General .....................................................................................50-11250.43.2 Support Payments.....................................................................50-11250.43.3 Unearned Income In-Kind .........................................................50-11350.43.4 Earned Income In-Kind .............................................................50-11450.43.5 $50 Child/ Spousal Support Deduction .....................................50-11450.43.6 Dependent Care Deduction.......................................................50-115



50.43.7 Other Health Coverage Premium..............................................50-11550.43.8 ABD-MN Deductions.................................................................50-115

Married Couple ....................................................................50-115Unmarried Couple ................................................................50-115Blind/Disabled Child .............................................................50-115

50.43.9 Income Determination Procedure .............................................50-11650.43.10 PA/ Other PA ............................................................................50-117

50.44 Federal Poverty Level and Property Waiver Programs (100%/133%/ 200% Income Disregard)....................................................................................50-11850.44.1 General .....................................................................................50-11850.44.2 Family Size ...............................................................................50-11850.44.3 Income ......................................................................................50-11850.44.4 Property ....................................................................................50-11950.44.5 Procedure to Determine FPL Eligibility .....................................50-11950.44.6 Examples ..................................................................................50-119

50.45 Share of Cost Considerations/NOAs........................................................50-12050.45.1 Multiple Shares of Cost .............................................................50-12050.45.2 Responsible Relative's Medical Expenses................................50-12050.45.3 Children's Medical Expenses ....................................................50-12150.45.4 Required Informing ...................................................................50-12150.45.5 Example of Medical Expenses..................................................50-12150.45.6 Hunt v Kizer ..............................................................................50-12150.45.7 Adjusting the SOC ....................................................................50-122

Situation 1 ............................................................................50-122Situation 2 ............................................................................50-122

50.45.8 Sneede NOAs ...........................................................................50-122

50.46 Sneede Budget Examples........................................................................50-12350.46.1 Example 1 .................................................................................50-12350.46.2 Example 2 .................................................................................50-12350.46.3 Example 3 .................................................................................50-124

50.47 Sneede Maintenance Need Income Levels (MNIL) and Property Limits .50-125

50.48 Court Orders: Radcliffe through ........................................Pettit v. Bontá50-126

50.49 Radcliffe v. Coye, et al .............................................................................50-12650.49.1 Issue .........................................................................................50-12650.49.2 Decision ....................................................................................50-126

50.50 Sawyer v Shalala, Anderson, Belshe, Gould ..........................................50-12750.50.1 Issue .........................................................................................50-12750.50.2 Decision ....................................................................................50-12750.50.3 Retroactivity ..............................................................................50-127

50.51 Tinoco v Belshe .......................................................................................50-128



50.51.1 Issue..........................................................................................50-12850.51.2 Decision ....................................................................................50-12850.51.3 Retroactivity ..............................................................................50-128

50.52 Gamma v Belshe .....................................................................................50-12850.52.1 Issue..........................................................................................50-12850.52.2 Decision ....................................................................................50-12950.52.3 Retroactivity ..............................................................................50-129

50.53 Ramirez v. Belshe ....................................................................................50-12950.53.1 Issue..........................................................................................50-12950.53.2 Decision ....................................................................................50-129

50.54 Latino Coalition for a Healthy California v. Belshe ...................................50-13050.54.1 Issue..........................................................................................50-13050.54.2 Decision ....................................................................................50-13050.54.3 Retroactivity ..............................................................................50-131

50.55 Pettit v. Bontá ...........................................................................................50-13150.55.1 Decision ....................................................................................50-13150.55.2 Retroactivity ..............................................................................50-131
