California Department of Social Services - State Hearings Division
Notes from the Training Bureau - September 7, 2001

Reference: Senate Bill (SB) 87; ACWDL 01-17

SB 87 mandates that counties continue §1931(b) Medi-Cal eligibility for persons discontinued from CalWORKs except in those circumstances where it is clear that such persons are ineligible for §1931(b) Medi-Cal. This ACWDL discusses changes in the Medi-Cal redetermination process including the ex parte redetermination process. The changes in the redetermination process must be fully implemented by July 1, 2001.

CalWORKs Discontinuances

Unless there is clear evidence that there is no §1931(b) eligibility (e.g., a person has died or is in prison), the county must continue to issue Medi-Cal benefits for persons discontinued from CalWORKs. CalWORKs cases discontinued for reasons such as failure to provide essential information or the monthly income report, or failure to cooperate with WTW requirements are not considered changes in circumstances that affect Medi-Cal eligibility. The former CalWORKs recipient should not be discontinued from Medi-Cal. Medi-Cal eligibility should be evaluated at the annual redetermination.

Thus if a CalWORKs case is approved in August 2000, and the CalWORKs case is discontinued at the end of November 2000 because the caretaker relative did not return the monthly report form, the county should continue to issue §1931(b) Medi-Cal until the annual redetermination in August 2001. If the county is aware of a change in circumstances that affects Medi-Cal eligibility before August 2001, the county may review eligibility and discontinue Medi-Cal as necessary.

The county shall make a Medi-Cal-only eligibility determination without the involvement of the persons discontinued from CalWORKs by using the ex parte process when a change in circumstances affecting Medi-Cal eligibility occurs. A table is included with this ACWDL that indicates when the ex parte redetermination process is required. It is required in the following circumstances: failure to complete the CalWORKs annual redetermination, loss of contact/whereabouts unknown, only eligible child leaves home, change in household composition that has resulted in non-cooperation in CalWORKs evidence gathering process, excess resources, excess income and failure to cooperate with child support requirements.

When the county uses the ex parte process, it shall attempt to determine Medi-Cal eligibility by checking open case records, and/or case records that have been closed within the last 45 days. In addition, the county may check other resources such as the Income Eligibility Verification System (IEVS), the Systematic Alien Verification for Entitlements (SAVE) system, the Employment Development Department, the State Data Exchange and the Beneficiary data Exchange.

When the ex parte process is unsuccessful in determining whether an individual is eligible for Medi-Cal, the county may contact the individual, but must document in the case record the exact reason for contacting him/her. The county shall attempt to contact the individual by telephone to request necessary information and also document all attempts to contact the individual.

When the ex parte process and telephone contact are unsuccessful, the county is required to send a Request for Information (MC 355) form to the person. ACWDL 01-39 fully discusses how and when the MC 355 should be used and provides a copy of the MC 355 form.

When the individual fails to respond to the MC 355 form or does not provide sufficient information within required time frames, counties are still required to evaluate the individual for other Medi-Cal programs without the additional information/verification.

Loss of §1931(b) Eligibility

Any person discontinued from CalWORKs who is ineligible for §1931(b) Medi-Cal, or who is discontinued from §1931(b)-only Medi-Cal due to increased earnings from employment or increased child/spousal support must be evaluated for Transitional Medi-Cal (TMC) and Four-month continuing programs.

CalWORKs Denials

CalWORKs denials shall be reviewed for Medi-Cal-Only eligibility through the ex parte process when the applicant has completed the SAWS 2 Statement of Facts form.

See also paraphrased regulations 410-16, 410-16A, 410-16B and 410-16C citing Welfare and Institutions Code (W&IC) §§14005.31 through .39 on this subject.