State of California—Health and Human Services Agency

Department of Health Care Services JENNIFER KENT Director

EDMUND G. BROWN JR. Governor

August 11, 2015

Medi-Cal Eligibility Division Information Letter No.: I 15-20 TO:

ALL COUNTY WELFARE DIRECTORS

ALL COUNTY WELFARE ADMINISTRATIVE OFFICERS

ALL COUNTY MEDI-CAL PROGRAM SPECIALISTS/LIAISONS

SUBJECT:

Supplemental Guidance on California Healthcare Eligibility, Enrollment, and

Retention System Release 15.3 Programming of Data Elements Required to

Correctly Determine Scope of Services for Certain Immigrants.

The purpose of this Medi-Cal Eligibility Division Information Letter (MEDIL) is to provide

supplemental guidance for county eligibility workers (CEWs) on California Healthcare Eligibility,

Enrollment and Retention System (CalHEERS) Release 15.3 programming of data elements

required to correctly determine scope of services for certain immigrants.

Background Prior to CalHEERS Release 15.3, CalHEERS was not able to correctly identify some immigrants as only being eligible for restricted scope rather than full-scope Medi-Cal. Release 15.3, deployed on March 1, 2015, utilizes two data fields to correctly determine scope of services for immigrants. These two data elements are: “Citizen” and “Eligible Immigrant”. Each of these data elements requires a “yes” or “no” response. When either of these two data elements is marked as “yes” for an otherwise eligible individual, (meaning the individual is identified as a United States Citizen or Eligible Immigrant), CalHEERS will grant full-scope benefits. When “Eligible Immigrant” is marked as “yes” then document information is also required by CalHEERS to process the eligibility request. When both of these two data elements are marked as “no” for an otherwise eligible individual, CalHEERS will grant restricted scope benefits. If both of these fields are left blank, the system assumes that the individual is neither a citizen nor an eligible immigrant and defaults to granting restricted scope Medi-Cal. This means that failure to populate or appropriately populate these data elements in the systems after the deployment of 15.3 can result in an incorrect eligibility determination or reduction from full scope Medi-Cal to restricted scope Medi-Cal for otherwise eligible beneficiaries. County Systems Guidance The three Statewide Automated Welfare Systems (SAWS) were affected differently by the new

requirements implemented in CalHEERS Release 15.3 related to immigrants. The Department of

Health Care Services (DHCS) has worked closely with county welfare departments, the County

Medi-Cal Eligibility Division

1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899-7417

(916) 552-9430 phone, (916) 552-9477 fax

Internet Address: www.dhcs.ca.gov

Medi-Cal Eligibility Division Information Letter No.: I 15-20 Page 2 August 11, 2015

Welfare Directors Association (CWDA), CalHEERS staff, and SAWS staff to ensure that eligibility workers are aware of the new Release 15.3 requirements regarding the citizenship and eligible immigrant fields so that erroneous eligibility determinations are not made and eligible immigrants are not reduced from full scope Medi-Cal to restricted scope Medi-Cal in error. Counties and/or SAWS staff have issued guidance to ensure that CEWs send the necessary citizenship or immigration status information in accordance with Release 15.3 and other CalHEERS and SAWS requirements. It is imperative that all CEWs immediately follow these guidelines to ensure correct eligibility determinations are made since Release 15.3 and to ensure eligible immigrants have not been reduced from full to restricted scope Medi-Cal in error. Counties must immediately assess the extent to which this issue has affected correct eligibility determinations made in their respective county since Release 15.3 and proactively identify and correct the eligibility of beneficiaries who were incorrectly determined eligible for restricted scope Medi-Cal and/or incorrectly reduced from full to restricted scope in error. DHCS, in conjunction with CWDA and SAWS will assist counties in proactively identifying and restoring full scope benefits to beneficiaries who were reduced to restricted scope benefits in error. Restoring Eligibility In the event a beneficiary has Medi-Cal reduced from full to restricted scope in error, counties must immediately change eligibility to full scope as appropriate. This includes providing a proper notice of action. When eligibility is reduced from full to restricted scope Medi-Cal for a case that is in a managed care health plan, a “59” hold will be put on the Medi-Cal Eligibility Data System (MEDS) record. This hold will prevent re-enrollment into managed care. Therefore, in cases where full scope Medi-Cal benefits are reduced in error and must be restored to full scope, counties must ensure that the 59 hold is removed from MEDS as well. To remove the 59 hold, counties must contact the Medi-Cal Managed Care Ombudsman after MEDS has been updated with the correct full scope aid code. The Managed Care Ombudsman may be contacted by use of a fillable form (county workers only). You may submit your Request of Change (e.g. a hold removal, expedited enrollment/disenrollment, or health plan change) on the new fillable form at: http://dhcs.ca.gov/mcombudsman. You will need to use a County e-mail address to submit your request. (This form is for Medi-Cal and Foster Care eligibility workers only.) Please ensure that the information in this MEDIL is disseminated to county staff, who deal with Medi-Cal eligible immigrants such as appropriate refugee, foster care, and California Work Opportunity and Responsibility for Kids (CalWORKs) program staff. If you have any questions or need further information regarding this letter, please contact Harold Higgins at (916) 322-5214 or by email at [email protected] Original Signed By: Alice Mak, Acting Chief Medi-Cal Eligibility Division

Supplemental Guidance on California Healthcare Eligibility ...

Department of Health Care Services. August 11, 2015. Medi-Cal Eligibility Division Information Letter No.: I 15-20. TO: ALL COUNTY WELFARE DIRECTORS.

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