Update : Medi-Cal A&D FPL Program: Change In Eligibility Determination For Couples And Clarifications

Transcription

1 Santa Clara County Social Services Agency page 1 Date: 10/01/02 References: ACWDL # Cross-References: Clerical: Handbook Revision: Distribution: N/A No Yes Medi-Cal Update Distribution List Update : Medi-Cal A&D FPL Program: Change In Eligibility Determination For Couples And Clarifications Background The Aged and Disabled Federal Poverty Level (A&D FPL) program, which became effective January 1, 2001, provides zero share-of-cost (SOC) Medi-Cal benefits to qualified individuals. Couples applying for the A&D FPL program were to be screened using the income limits for a couple. If they didn t pass the income test, then neither member was eligible for the A&D FPL program. Change Effective 10/01/02, couples who do not pass the budget computation for the A&D FPL program must be screened individually using a second budget. [Section ] Second Budget On the second budget, one spouse is screened for the A&D FPL program and the other spouse is considered an ineligible (IE) A&D FPL spouse. A Maintenance Need (MN) Deduction of $600 is allowed for the needs of the IE A&D FPL spouse. However, only one spouse of the couple can be eligible for the program following these instructions. Switching Status Couples have the option of switching status between either the selected spouse for the A&D FPL program and the IE A&D FPL spouse. There must be a lapse of al least one month of eligibility before an eligible spouse can switch status with the other spouse. The couple must notify the Eligibility Worker (EW) prior to MEDS cutoff for eligibility to take effect on the first of the following month. If not, eligibility would occur in the future-future month.

2 page 2 Update : Medi-Cal Implementation The information contained in this Update is effective 10/01/02. Intake EWs Intake EWs must follow the updated eligibility criteria for couples effective 10/01/02, and follow the steps outlined under the EW Action Section. Continuing EWs Continuing EWs must identify couples, on the Ad Hoc listing dated 10/01/02 (Refer to Data Systems Section), who are potentially eligible for the A&D FPL program, and follow the steps outlined under EW Action Section. EW Action EWs must follow these procedures to apply the change when determining A&D FPL eligibility for couples: STEP ACTION 1. Intake EWs: If the couple fails the first income test, go to step 2. Continuing EWs: Identify couples on the Ad Hoc listing dated 10/01/02 who are potentially eligible for the A&D FPL program, and go to step Reevaluate eligibility under the A&D FPL program by doing the following: Compute a SECOND budget by completing the Aged & Disabled Federal Poverty Level Program Financial Eligibility Worksheet (MC 176-A&D FPL Group) when a couple did not pass the first income test. Use the income from both spouses to determine eligibility for only ONE of the spouses. The couple can decide which spouse will benefit the most (the spouse who has greater medical needs). The other spouse is considered an ineligible (IE) A&D FPL spouse. 3. Determine the Nonexempt Income (Section III -MC 176-A&D FPL Worksheet): - Enter the Total Earned and Unearned Income of both spouses (line 15) - Allow the current Disregard for the Qualified Individual of $230 (line 16) - Allow Health Insurance Premiums (line 17) - Allow ABD-MN Deductions (line 18) - Allocate $600 Maintenance Need for the IE A&D FPL spouse (line 19) - Determine Nonexempt Income (line 20) - Enter $739, the 100% FPL for ONE effective 04/01/02 (line 21) - Compare lines 20 & 21. The client is eligible if the amount on line 20 is less than or equal to the amount on line 21. If the selected spouse passes the second test, this spouse is determined eligible for the A&D FPL program. If the selected spouse does not pass the second test, the couple is not eligible for the A&D FPL program and a denial Notice of Action (NOA) must be sent. Explore eligibility under other Medi-Cal programs (i.e., 250% Working Disabled Program [WDP], Aged, Blind and Disabled - Medically Needy [ABD-MN] with a share-of-cost [SOC], etc.). 4. Set up A&D FPL program for the spouse determined eligible and issue the appropriate approval NOA. Explore eligibility for the IE A&D FPL spouse under other Medi-Cal programs (i.e., 250% WDP, ABD-MN with SOC, etc.) and issue the appropriate NOA(s).

3 Update : Medi-Cal page 3 Computation Example Attached is an example of an aged couple applying for the A&D FPL program who did not pass the first income test. However, one of them passed the second test. Both spouses receive Social Security Administration (SSA) benefits. On a monthly basis, the husband receives $900 and his wife $650. [See Attachment #1 for the First Income Test, and Attachment #2 for the Second Income Test] Data Systems The following listing is created to assist eligibility staff in Continuing: Ad Hoc Listing An Ad Hoc listing will be distributed to continuing staff on 10/01/02 which identifies couples receiving Medi-Cal with a SOC and who are potentially eligible for the A&D FPL program. QMB/SLMB The following information is not new but is provided as a reminder. Qualified Medicare Beneficiary/Specified Low-Income Medicare Beneficiary (QMB/SLMB) programs are not affected by the A&D FPL change. Dually eligible A&D FPL clients must be evaluated for the QMB/SLMB programs. However, financial eligibility can no longer be calculated automatically by CDS as it is now for dually eligible (Medicare/Medi-Cal) clients. The following manual procedures must be used: STEP ACTION 1. Calculate QMB financial eligibility using the MC 176 QMB/SLMB Compare the income to the QMB/SLMB charts in Chapter 5 of the Chart Book. 3. Set up QMB or SLMB as appropriate on the next available 80 FBU using current EDP procedures. [Refer to User s Guide for further information.] EW Supervisors EW Supervisors must review the information contained in this Update at their next unit meeting but no later than 10/16/02. Commonly Asked Questions This Update contains frequently asked questions regarding the A&D FPL program. The State has researched and provided the following answers. Income Limits Q: How are the income limits for the A&D FPL program determined? A: The income limits are determined by using 100% of the FPL for either an individual or couple, plus the corresponding income disregard. The yearly Title II Social Security Cost of Living Adjustments effective in January are deferred until the new FPL income limits are out in April. Also, the A&D FPL income limits cannot be less than Supplementary Security Income/State Supplementary Program (SSI/SSP) levels for an individual or a couple.

4 page 4 Health Care Premium Deduction Update : Medi-Cal Q: Can health care premiums be allowed as a deduction for the A&D FPL program? A: Yes. All ABD-MN deductions can be allowed as a deduction with the exception of the In-Home Supportive Services deduction for the A&D FPL program. [Refer to Medi-Cal Handbook Sections 56 and 57 for further information regarding ABD-MN deductions.] Public Assistance (PA) Q: Is the A&D FPL program considered a Public Assistance (PA) program, and are Section 1931(b) clients considered other PA? A: No. The A&D FPL program is not considered a PA program, and for A&D FPL program purposes, Section 1931(b) clients are not considered other PA. Medicare Part B Premium Q: Can Medi-Cal beneficiaries choose to pay their own Medicare Part B premium once the Buy-In process starts, so they can become eligible for the A&D FPL program? A: No. The Department of Health Services (DHS) participates in a Medicare Buy-In agreement with the Centers for Medicare and Medicaid Services (CMS). The Buy-In agreement requires DHS to pay the Medicare Part B premium for all cash grant and medical assistance only (MAO) beneficiaries. The A&D FPL program is considered MAO. Substantial Gainful Activity (SGA) Q: What is the policy regarding Substantial Gainful Activity (SGA) and the A&D FPL program? A: DHS has verified that there are no SGA exemptions for the A&D FPL. Eligibility for Couples Q: What are the options for couples that might qualify for the A&D FPL? A: If the couple is eligible, they both qualify for the A&D FPL program. However, if they both cannot qualify as a couple for the A&D FPL, the couple may apply as individuals, if one of them qualifies individually. The individual who chooses not to be enrolled in the A&D FPL program, may choose not to receive Medi-Cal, or the couple may qualify for the MN program with a SOC. It is possible for a couple to be in two different programs. NELLIE JORGE, DIRECTOR Department of Employment and Benefit Services Contact Person(s): Guillermo Cáceres, Program Coordinator, (408)

5 Santa Clara County Social Services Agency page 1 Date: 10/01/02 Filing Instructions for Update : Medi-Cal A&D FPL Program: Change In Eligibility Determination For Couples And Clarifications Remove Replace with Chapter 38, pages 3-6 (05/31/02) Chapter 38, pages 3-8 (10/01/02)

6 page 2 Filing Instructions for Update : Medi-Cal