Full Scope Medi-Cal For Older Adult Expansion

MEDI-CAL

Full Scope Medi-Cal For Older Adult Expansion

Release Date

04/28/2022

Section Heading

Purpose

To convert existing policy to the new webpage - No content changes.

Revision of existing policy.

Policy

Effective May 1, 2022, full scope Medi-Cal benefits will be expanded to individuals 50 years of age or older who do not have Satisfactory Immigration Status (SIS) or are unable to establish SIS, if otherwise eligible. This change in policy is referred to as the Older Adult Expansion (OAE). The impacted populations are:

New Enrollee Population

The new enrollee population consists of individuals who are 50 years of age or older in May 2022, do not have SIS, are not currently enrolled in Medi-Cal, apply for Medi-Cal after the implementation of the OAE, and meet all eligibility criteria for full scope Medi-Cal benefits, under any eligibility group, including Modified Adjusted Gross Income (MAGI) and Non-MAGI.

Transition Population

The transition population consists of individuals who are 50 years of age or older and are currently enrolled in restricted scope Medi-Cal because they were not in a SIS for full scope Medi-Cal under any eligibility group, including MAGI and Non-MAGI, before implementation of this expansion.

Background

Assembly Bill (AB) 133 (Budget Act of 2021) amended the Welfare and Institutions Code (WIC) section 14007.8 to expand eligibility for full scope Medi-Cal to individuals who are 50 years of age or older, and who do not have SIS or are unable to establish SIS as required by WIC section 14011.2, if otherwise eligible.

Full scope Medi-Cal benefits include, but are not limited to medical, vision, dental, mental health, and alcohol and drug treatment services.

Effective May 1, 2022, both the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) and the California Statewide Automated Welfare System (CalSAWS) are programmed to grant full scope Medi-Cal to eligible new applicants 50 years of age or older. Additionally, both systems and the counties will transition current Medi-Cal beneficiaries who are 50 years of age or older from restricted scope Medi-Cal to full scope Medi-Cal.

Definitions

Terms and Descriptions

CalHEERS

The automated system managed at the State level, which contains the business rules engine used to evaluate eligibility for Modified Adjusted Gross Income (MAGI) Medi-Cal and programs offered by Covered California.

CalSAWS

County system(s) used to determine eligibility and benefit determination, enrollment, and case maintenance for some of the different health and human services programs (including Medi-Cal, California Work Opportunity and Responsibility to Kids [CalWORKs], and CalFresh).

SIS

For Medi-Cal purposes, means lawful admission for permanent residence in the United States, status as an alien permanently residing in the U.S. under color of law, or status as an amnesty alien.

Permanently Residing Under Color of Law (PRUCOL)

PRUCOL is a public benefits category created by the federal courts that grants full scope Medi-Cal eligibility to immigrants residing “under the color of law.” For a person to be residing “under the color of law,” the United States Citizenship and Immigration Services (USCIS) must know of the person’s presence in the U.S. and provide the person with written assurance that enforcement of deportation is not planned. PRUCOL is not recognized as an immigration status by the USCIS.

Reasonable Opportunity Period (ROP)

A period of 90 days from the application date to allow applicants and/or beneficiaries to submit verification of citizenship or SIS.

Federal Data Services Hub (FDH)

Electronic verification system used to compare and verify information with other federal and State systems.

Fee-For-Service (FFS)

Medi-Cal delivery system where health care providers are paid for each service (e.g., an office visit, test, or procedure).

Requirements

Age Policy

CalHEERS and CalSAWS will use the following age policy to determine who is eligible for the OAE, if otherwise eligible:

Due to whole month eligibility, when an individual turns 50 years of age they will be eligible for full scope Medi-Cal for the entire month if they are otherwise eligible.

Example: Individuals who turn 50 years of age between May 1, 2022, and May 31, 2022, are considered age 50 for the entire month of May 2022, and are eligible for full scope Medi-Cal under any eligibility group, including MAGI and Non-MAGI, under the OAE.

The same rule applies to applicants and beneficiaries that turn 50 years old in subsequent months.

Application Process

Individuals can apply for Medi-Cal online, by mail, telephone, fax, or in person. If the applicant qualifies for full scope Medi-Cal under the OAE, they will receive the appropriate Notice of Action (NOA) notifying them of their eligibility for full scope Medi-Cal effective May 2022.

Retroactive Coverage

New applicants can request retroactive Medi-Cal coverage for up to three months prior to the month of application. However, eligible OAE individuals who request retroactive coverage, for any month(s) prior to May 2022, will be granted restricted scope Medi-Cal for those months, based on eligibility policies in effect prior to implementation of the OAE.

Transition Process

A beneficiary must have been in an active restricted scope Medi-Cal eligibility effective the OAE implementation date to be automatically transitioned to full scope coverage. CalSAWS transitioned current eligible Medi-Cal individuals from restricted scope to full scope on April 8, 2022. The Department of Health Care Services (DHCS) notified individuals in restricted scope aid codes of the transition process and that no action was required on their part.

Effective April 8, 2022, CalSAWS:

Identified eligible individuals 50 years of age or older enrolled in restricted scope MAGI or Non-MAGI Medi-Cal aid codes and processed the transition into full scope aid codes via CalHEERS, based on the OAE Aid Code Crosswalk Chart.
Used a batch process to identify the MAGI and Non-MAGI OAE transition population and transmitted the appropriate aid code change to the Medi-Cal Eligibility Data System (MEDS).
Generated and sent the appropriate NOA to inform transitioned beneficiaries that their level of benefits will increase from restricted to full scope Medi-Cal coverage.

Medi-Cal Managed Care Enrollment

Both the new enrollee population and transition population will need to enroll in a managed care plan.

Applicants
Applicants approved for Medi-Cal will have FFS full scope Medi-Cal effective the first month of eligibility and will then receive a Managed Care Enrollment Packet.
Beneficiaries
Will have received the following materials from DHCS:
1. A Medi-Cal Choice Packet in their threshold language at the end of March 2022.
2. A Medi-Cal Managed Care Enrollment Notice with Frequently Asked Questions in April 2022.
3. An Enrollment Choice form;
4. A self-addressed stamped envelope to return the completed form;
5. A Medi-Cal managed care plan enrollment choice booklet that provides health plan information;
6. Guidance on how to enroll in a Medi-Cal managed care plan or change plans;
7. The Health Care Options presentation schedule;
8. A summary list of Medi-Cal managed care plan benefits;
9. Instructions and forms for the Medical Exemption Request/Waiver; and
10. A Medi-Cal managed care plan provider directory for their county.
  Note: Individuals who do not select a health plan will default into a managed care plan.

Note: Eligibility staff should refer to the References Section for previously released information related to OAE.

Annual Renewals

When an OAE eligible individual transitions from restricted scope Medi-Cal to full scope Medi-Cal due to the implementation of the OAE, the Medi-Cal annual renewal date will not be reset. Since the OAE is an increase in the level of benefits for the individual, it is not considered a change in circumstance; therefore, a change to the renewal date is not required and the renewal date should remain unchanged.

At the end of the Public Health Emergency (PHE), eligibility staff will have to complete renewals on these cases. Additional information will be provided at that time.

Report Changes within 10 Days

Medi-Cal applicants and beneficiaries must report any changes to their citizenship or immigration status of any family member who is applying for or receiving Medi-Cal to their Eligibility Worker (EW) within 10 days.

Verification Docs

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Attachments

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