DPSS ePolicy

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The purpose of this release is to provide information related to policy and procedures for individuals who are discontinued from CalWORKs (CW) and are placed into Aid Code 38, or a Consumer Protection Program (CPP).

What changed?

1. Effective November 25, 2019, the LEADER Replacement System (LRS) will no longer automatically generate and send the Request for Tax Household Information (RFTHI) form for individuals placed in aid code 38.
2. Following an ex-parte review, staff will need to manually issue the RFTHI form, if needed.

Changes are shown highlighted in grey throughout the document.

Medi-Cal (MC) policy requires that individuals who are placed in aid code 38, or a CPP after being discontinued from CW, must undergo an eligibility determination for all health insurance affordability programs.

As part of this process, an ex-parte review must be conducted prior to requesting any information required to determine ongoing MC eligibility.  If needed, the RFTHI form is used to collect the tax household and income information to proceed with an eligibility determination for ongoing benefits.

If the RFTHI is not returned, or the information requested by the RFTHI is not provided, and the only missing information is related to the tax household, the eligibility determination will be completed utilizing Non-Tax Filer Rules.  Benefits are not to be discontinued.

LRS is programmed to perform an auto-test to determine if an individual is potentially eligible to ongoing benefits as a result of a CW discontinuance.

LRS is programmed to automatically open a new MC block in the existing CW case, or add the individuals to an existing MC block.  Policy requires that an ex-parte review be conducted prior to initiating a request for information from the customer, effective November 25, 2019, LRS will no longer automatically generate and send an RFTHI for all active individuals in the MC block as a result of a CW discontinuance.  This step will now be performed by staff manually.

Discontinuance from CalWORKs

When a recipient is discontinued from CW for reasons that would not affect their MC eligibility, LRS will perform a preliminary evaluation (auto-test) to determine if the individual is potentially eligible for ongoing MC benefits.

Medi-Cal Program Block

The MC Program block will consist of the CW discontinued individual(s), and any other individuals in the household, including those individuals who may still be receiving CW benefits under the CW block.

Individuals who are still receiving CW benefits do not receive benefits under the MC Program block.  These individuals are added to MC block as Unaided Persons (UP), because they are part of the same household as the CW discontinued individual(s) who is being evaluated for MC.

After creating a new MC Program block, or adding eligible individuals to an existing MC Program block, LRS will automatically:

• Run and accept EDBC; 
• Authorize the transaction; and
• Issue a Notice of Action (NOA).

Prior to placing the CW discontinued individual in aid code 38 in the MC Program block, LRS will determine if the individual is eligible for any Consumer Protection Program (CPP) such as:

• Continuous Eligibility for Children (CEC):  7J
• Transitional Medi-Cal (TMC):  39/3T and 59/5T
• Four-Month Continuing:  54/5W

As a result, you may have different outcomes within the MC Program block, depending on the type of eligibility that the discontinued CW recipient is potentially eligible to.

All Eligible Under a CPP

If all are eligible under a CPP, the individual(s) will remain eligible to zero Share-of-Cost (SOC) MC benefits until the end of the protection period, and will be added to the MC Program block with the appropriate CPP aid code above.

In addition, if the individual(s) added to the MC Program block are only eligible under a CPP, they do not require another eligibility determination until the end of the protection period or at the next annual Renewal.

Once the CPP period ends, LRS will update the individual(s) aid code from the previously issued CPP aid code, to aid code 38.  Once this occurs, an ex-parte review must be conducted to determine ongoing MC benefits.

All Eligible Under Aid Code 38

If all individuals are eligible to aid code 38, an ex-parte review must be conducted.  If the ex-parte review is not successful, the RFTHI form must be manually issued with a 30-day due date to request tax household and/or income information before proceeding with the eligibility determination.

Combination of Individuals Eligible Under a CPP and Aid Code 38

When the MC Auto-Test results in individuals being eligible to a CPP aid code, but there is at least one individual in aid code 38, an ex-parte review must be conducted.  If the ex-parte review is not successful, the RFTHI form must be manually issued for all individuals with a 30-day due date before proceeding with the eligibility determination.

Upon receipt of the RFTHI(s), all CPP eligible individuals will be evaluated for ongoing MC benefits simultaneously with individuals in aid code 38.  If MAGI eligible, CPP individuals will be issued the appropriate MAGI aid code, and their CPP eligibility will end.  If not MAGI eligible, CPP individuals must remain in their CPP aid code until the end of the protection period or next annual Renewal.

Refer to the Examples section of this document for a table that displays who would be included in the MC Program block following a CW discontinuance for a child aging-out of CW.

Request for Tax Household Information Form

After creating the MC Program block, if at least one household member is placed in aid code 38 and tax household status information cannot be obtained via the ex-parte review, a RFTHI form must be manually issued for each active household member in the MC Program block. 

Household members who are included in the MC Program block, but not in an active status, do not have to be sent an RFTHI.  For example, an individual who is part of the household, but is receiving Supplemental Security Income (SSI).

The information collected by the RFTHI is needed to determine tax household composition in order to conduct an eligibility determination for MAGI MC.  The information collected via the RFTHI is also used when conducting an eligibility determination for:

•  Advanced Premium Tax Credits (APTC)/Cost Sharing Reductions (CSRs); and 
• Unsubsidized Coverage.

Staff are reminded that the actual RFTHI form does not need to be returned as long as the information requested is provided by the individual(s).  The information may also be provided over the phone.

In addition to the RFTHI form(s), the following documents are also included in the mailing:

• A Departmental Cover Page that displays the date the RFTHI form(s) were sent, along with case and worker information, and the case mailing address. 
• The RFTHI Cover Letter that includes the due date (which is 30 days from the date on the Departmental Cover Page) by which the RFTHI form(s) must be returned. 
• The RFTHI Supplemental Form.

For instructions on how to access, view, and update the status of the RFTHI form in LRS, refer to the Procedures section in this administrative release. 

Point of Contact

Unlike MC Renewal processing, there is no additional contact with the household once the RFTHI has been issued.  LRS will not:

• Issue a reminder notice; or 
• Initiate an automated outbound call.

However, if the household returns an incomplete RFTHI that does not include all of the information needed to establish the tax household composition, eligibility staff should attempt to contact the individual(s) by telephone to obtain the information that was not provided, prior to updating the form as Received. 

This includes instances where more than one RFTHI was issued for a household, but not all forms were returned.

If after two documented attempts to contact the beneficiary, the information could not be obtained, and the only information needed to proceed with an eligibility determination is tax household information, staff must treat the individual(s) as Non-Tax Filers and determine ongoing MC eligibility.  Each contact and action taken must be clearly documented in the case journal, including the date and time the contact was made.

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