Non-MAGI Evaluation for Individuals in Soft Pause

MEDI-CAL

Non-MAGI Evaluation for Individuals in Soft Pause

Release Date

10/23/2018

Section Heading

Purpose

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

Policy

Soft Pause is a system functionality that protects beneficiaries from losing their Modified Adjusted Gross Income (MAGI) Medi-Cal (MC) coverage, while an evaluation of eligibility for Non-MAGI MC or Consumer Protection Programs (CPP) is completed. This functionality happens when a MAGI beneficiary that meets Soft Pause Group criteria becomes ineligible for MAGI MC due to a change in circumstances (e.g. increase in income).

Soft Pause Groups

Aged 65 or older;
Blind;
Disabled;
Becoming eligible for Medicare;
Children under age 21;
Parent/caretaker relative of a child under age 21; or
Pregnant person with income over 138% of the Federal Poverty Level (FPL), up to the end of the 60-day post-partum period.

Actions that trigger the Soft Pause Functionality

Increase in income or decrease in the Tax Household that will move an individual from:
- MAGI MC to Advance Premium Tax Credits (APTC)/ Cost Sharing Reductions (CSR) subsidies;
- Non-premium MAGI MC to premium MAGI MC;
Full scope MAGI MC to limited or restricted scope MAGI MC (including Pregnancy Related MC);
Turning age 65; or
Becoming eligible for Medicare before age 65.

Background

Welfare and Institution Code (WIC) 14005.37 states that whenever a county receives information about changes in a beneficiary’s circumstances that may affect eligibility for MC, the county shall redetermine eligibility. In the meantime, MC benefits will continue until the redetermination of eligibility is completed.

Definitions

Terms and Descriptions

Modified Adjusted Gross Income (MAGI)

A methodology for evaluating income to determine MAGI MC and APTC/CSR eligibility. MAGI is defined by the IRS as Adjusted Gross Income (AGI) plus foreign income, tax exempt interest, and the full amount of Social Security benefits.

MAGI Medi-Cal

Income based MC program that utilizes the MAGI methodology to determine eligibility.

Non-MAGI Medi-Cal

Income and property-based MC program that existed prior to the implementation of the Affordable Care Act (ACA), and continues to provide MC coverage under the following programs:

Aged (65 or over), Blind, or Disabled;
Long-Term Care (LTC);
Medicare Savings Programs (MSP);
Medically Needy;
250% Working Disabled Program;
Pickle;
Minor Consent; and
Sneede vs. Kizer.

Mixed Household (HH)

This is a term used for households being aided through multiple health care programs:

Mixed HH MC
- MAGI MC + Non-MAGI MC.
Mixed HH APTC/CSR
- MAGI MC + APTC/CSR;
- Non-MAGI MC + APTC/CSR; or
- MAGI MC + Non-MAGI + APTC/CSR.

Consumer Protection Programs (CPP)

Programs that protect beneficiaries from losing their existing level of MC coverage due to a reported change in circumstances.

CPP include:

Continuous Eligibility for Children (CEC);
Transitional MC (TMC);
Four-Month Continuing;
Deemed Eligibility for Infants (DE);
Eligibility for Pregnant person; and
60-day post-partum period.

Covered California (CoCA)

California’s health care market place where individuals can apply for health insurance affordability programs (MC/APTC/CSR). Users can create an account to apply for health care, enroll in coverage, and report changes for their CoCA plan and/or MC case.

Advanced Premium Tax Credits (APTC)/Cost Sharing Reduction (CSR) Subsidies

Income based programs that provide subsidies in the form of tax credits, or help in paying out-of-pocket expenses such as deductibles and co-payments. Qualified individuals who are not eligible to MAGI MC or are eligible to Non-MAGI MC with a share of cost (SOC), can buy health insurance and receive APTC/CSR through CoCA.

Note: APTC/CSR cases without MC eligible members are managed by CoCA.

Open Enrollment Period (OEP)

A designated period each year when individuals can enroll in a health insurance plan through CoCA. Open enrollment for CoCA plan takes place during the fall.

Note: MC (MAGI and Non-MAGI) is open for enrollment throughout the year and is not subject to open enrollment periods.

Special Enrollment Period (SEP)

Period outside of the OEP that allows an individual or family to enroll or change a plan due to a Qualifying Life Event (QLE).

Qualifying Life Event (QLE)

Life change event(s) that can qualify an individual or family for a special enrollment period. Life change events include pregnancy, marriage, divorce, release from incarceration, moving to another state, moving to a new plan area, loss of minimum essential coverage, or other special circumstances, etc.

Note: Losing full scope MC is a QLE.

Change in Circumstances (CIC)

A reported change in circumstances that requires a redetermination of eligibility, and if found eligible, establishes a new 12-month period of eligibility.

Minimum Essential Coverage (MEC)

A requirement that most U.S. citizens and Legal Permanent Residents (LPRs) be enrolled in a health insurance plan that meets basic minimum standards.

Requirements

Non-MAGI Determination

Beneficiaries in Soft Pause must be evaluated for Non-MAGI MC or Consumer Protection Programs (CPP).

Note: Beneficiaries who are in Soft Pause and are moving from non-premium MAGI MC to premium MAGI MC, do not need to be evaluated for Non-MAGI MC.

The Non-MAGI determination must include an ex-parte review of all available information before requesting any documentation from the beneficiary in Soft Pause. If eligibility to Non-MAGI MC or a CPP cannot be established through an ex-parte review, the beneficiary must be mailed the Non-MAGI Screening Packet (NMSP) and allowed 30-days to return the requested information.

The required forms and verifications must be returned to proceed with Non-MAGI MC evaluation. Beneficiaries who do not comply by providing the required information are to be:

Discontinued from MAGI MC;
Granted a QLE; and
Referred to CoCA.

If the required information is provided within the 90-day cure period, and the beneficiary is determined to be eligible to Non-MAGI MC, benefits must be reinstated back to the date of the discontinuance.

Note: Income and property verifications are required for a Non-MAGI MC evaluation.

Non-MAGI Screening Packet

This packet is mailed to beneficiaries in Soft Pause whose eligibility could not be redetermined via an ex-parte review.

Form/Letter/Brochure and Descriptions

Non-MAGI Informing Letter (N-MIL)

This letter:

Informs the beneficiary that he/she is no longer eligible for MAGI MC.
Informs the beneficiary that he/she may still be eligible to Non-MAGI MC.
Provides the option for the beneficiary to request an evaluation for:
1. Other MC programs such as, Non-MAGI MC, and/or
2. APTC/CSR.
Informs the beneficiary that he/she may be enrolled in a no SOC or SOC Non-MAGI MC program if found eligible.
Provides an overview of Non-MAGI MC and APTC/CSR programs.

Note: Beneficiaries eligible for no SOC Non-MAGI MC are not eligible for APTC/CSR.

MC 604 IPS - Additional Income and Property Information Needed for Medi-Cal

This form captures the required property/assets, income, and expense information to evaluate the beneficiary for Non-MAGI MC.

Note: The signed MC 604 IPS must be returned along with the requested verification(s) within 30 days.

PUB 10 - Non-MAGI Medi-Cal

This brochure provides detailed information regarding the Non-MAGI MC program requirements.

Covered California Brochure

This brochure provides information regarding APTC and CSR.

Note: The NMSP must not be initiated if all MC beneficiaries in the case are eligible for a CPP.

Verification Docs

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Attachments

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