Mcchap25 Medically Needy (mn) Medi-cal_f

Medi-Cal Handbook

page 25-1 Medically Needy (MN) Medi-Cal

25. Medically Needy (MN) Medi-Cal

25.1 AFDC-MN — Linkage in General [50205] 25.1.1

Overview of Linkage

A person or family may be eligible to receive Medi-Cal benefits under any one of many programs, including Public Assistance (PA) programs which provide cash assistance, such as CalWORKs and SSI/SSP, as well as programs that provide only Medi-Cal benefits. The Medi-Cal only programs include the Section 1931(b) program, the Medically Needy (MN) program, the Medically Indigent (MI) program, and a variety of miscellaneous special Medi-Cal programs that cover specific medical needs. CalWORKs, SSI/SSP, Section 1931(b) and the MN programs have a requirement that the individual have a factor that links him or her to the program. This factor is referred to as linkage or deprivation. Eligibility shall be determined under the Section 1931(b) and/or the MN programs if the applicant has linkage for a cash program but is not eligible to cash for a reason other than linkage, or does not want to receive cash assistance. The Section 1931(b) and AFDC-MN programs require that the individual or family meet one of the linkage requirements through deprivation of parental care and support of a child. Linkage through deprivation requires at least one child be living in the home with a parent (married or unmarried) or a nonparent caretaker relative. An unrelated child whose adoption is still in process cannot provide linkage to the adoptive parents until the adoption is final.

25.1.2

Nonparent Caretaker Relative (50085)

The nonparent caretaker relative is a relative who provides care and supervision to a child when there is no natural or adoptive parent in the home. A nonparent caretaker relative cannot be aided if the adult parent is in the home unless the adult’s parental rights have been terminated. Update # 2007-10

Revised: 11/16/07

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The nonparent caretaker relative must be in the home providing care and supervision, and be of the same degree of relationship as required by the CalWORKs program. [Refer to “Caretaker Relative Rules and Requirements [50084],” page 60-6.] [Refer to “Caretaker Relatives,” page 23-18 for information related to Section 1931(b) cases.]

Nonparent Caretaker Relative who is a Spouse or Parent The nonparent caretaker relative with a spouse and/or child(ren) of his/her own, may be linked to related children when: • The caretaker’s spouse and/or child(ren) do not want Medi-Cal, or • The caretaker’s spouse and /or child(ren) are eligible and receive Medi-Cal but the caretaker relative has no linkage in that MFBU. The caretaker relative who is a spouse or parent therefore may be in two separate MFBUs. Example: Grandmother requests Medi-Cal for herself, her grandchildren, her spouse and her own children. The grandfather and their children live in the home. The grandfather has no linkage. The grandmother has no basis for linkage except as a nonparent caretaker relative to her grandchildren. The household consists of: caretaker, related children, caretaker’s spouse; their own children. There are two MFBUs. MFBU #1 has the caretaker and related grandchildren and MFBU #2 has the caretaker and the caretaker’s spouse as ineligible (IE) members and their own eligible children. NOTE: When the nonparent caretaker is in two MFBUs, consider the caretaker’s full income in both and allow his/her medical expenses to be used to meet the share of cost in both.

Treatment of Income and Property In households where there is an MFBU which contains a nonparent caretaker relative and related children and the spouse or children of the caretaker either do not wish Medi-Cal or do not receive public assistance (PA) or other PA and do not appear in any MFBU, no income or property of the caretaker’s spouse or own children is counted other than income which is actually contributed to the MFBU. Revised: 11/16/07

Update # 2007-10

Medi-Cal Handbook

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The EW must ask the caretaker relative if any of the spouse’s or children’s income or property is contributed and available to the caretaker. Count only that income or property that is declared to be available. Example: Grandmother requests Medi-Cal for herself and her grandchildren. The Grandfather and their children also live in the home. Grandfather has no linkage and does not wish Medi-Cal nor do their own children. The household consists of: caretaker, related children; caretaker’s spouse; their own children.There is one MFBU with the caretaker and the related grandchildren. NOTE: No income or property of the caretaker’s spouse or natural children is counted, except income that is actually contributed to the MFBU.

25.1.3

Who is eligible for the AFDC-MN program

The following persons may be eligible for Medi-Cal under the AFDC-MN Program: 1. A child(ren) who is living with a parent or caretaker relative and has any of the following deprivations: • • • •

Deceased Parent. Incapacitated Parent. Absent Parent. Unemployed Parent.

If there is more than one deprivation factor, linkage to AFDC may be established on the basis of any deprivation listed above. The EW shall explain the advantages/disadvantages of each. The deprivation shall be the choice of the parent/caretaker. Note: A child who is INELIGIBLE or who has been EXCLUDED from the MFBU unless PA or other PA (e.g. CalWORKs, SSI) cannot be considered when determining deprivation linkage. [Refer to “No Family Member in LTC or Board and Care [50371],” page 60-11 for more information.] 2. The parent(s) of the child(ren), or 3. The nonparent caretaker relative of the child(ren).

Update # 2007-10

Revised: 11/16/07

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4. A nonparent caretaker relative may be in the MFBU with the children and be linked to Medi-Cal by the death or absence of the child(ren’s) parents. 5. A caretaker relative may have linkage due to a child who is receiving PA or Other PA. 6. When a nonparent caretaker relative has his/her own linkage factor (ABD) he/she may choose to be included in the children’s MFBU or in a separate MFBU. Example: Grandmother (age 66) requests Medi-Cal for herself and her grandchildren. There is no spouse or children of her own in the home. She may be linked to the grandchildren and included in the same MFBU with them unless she requests otherwise because she has her own linkage (i.e. aged). If she does not request Medi-Cal she is not included in the MFBU. (If the grandchildren are receiving PA or other PA, Grandmother is the only person in an MFBU of 1) 7. The spouse of the child's parent when the deprivation is incapacity. 8. The spouse of the child's parent, when the spouse also has children from a prior union and the only deprivation is deceased/absent parent.

25.2 Deceased Parent Deprivation[50209] Deprivation of parental support or care exists if either of the child's parents is deceased. The death of a parent links the children, the remaining parent or a nonparent caretaker relative of the children Note: Client's sworn statement on the MC210 is sufficient to establish this deprivation, unless there is reason to believe that the statement is questionable.

Revised: 11/16/07

Update # 2007-10

Medi-Cal Handbook

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25.3 Incapacitated Parent [50211] Deprivation of parental support or care exists if either of the child's parents is physically or mentally incapacitated. Incapacity provides linkage for the children of the incapacitated parent, the incapacitated parent, the second parent of the children if living in the home, and the spouse of the incapacitated person, (i.e. the stepparent of the deprived children). The physical or mental illness, defect or impairment must be EXPECTED TO LAST AT LEAST 30 DAYS AND: • Reduce substantially or eliminate the parent's ability to support or care for the child, or • Prevent the parent from working full-time at a job in which he/she is customarily engaged, or • Prevent the parent from working a full-time job for which he/she is equipped by education, training, experience or which could be learned by on-the-job training, or • Cause employers to refuse to employ the parent for work the parent could do and is willing to do because of behavioral or other disorders which interfere with the securing and maintaining of employment, or • Prevent the parent from accomplishing as much on the job as a regular employee and, as a result, the parent is paid on a reduced basis, or • Establish for the parent, linkage to Adult-MN as blind or disabled; or • Cause the parent to be qualified for and employed in a job which is rehabilitative, therapeutic, or is in a sheltered workshop, and which is not considered to be full-time.

25.3.1

Establishing Incapacitated Parent Deprivation

Incapacitated Deprivation shall be established by one of the following: • Written statement by a physician, a licensed or certified psychologist, or authorized staff member on doctor's letterhead. Update # 2007-10

Revised: 11/16/07

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• Completed “Medical Assessment of Employability Status” (SC 76) Form. • Current DM 3 or MC 221. • Receipt of SSA, SSI/SSP or R/R Board benefits based on total and permanent disability or blindness. • Receipt of SDI or Worker's Compensation. • Verbal statement from a physician, licensed or certified psychologist or authorized member of their staff may be accepted for 60 days, pending receipt of written verification. Document in the [Maintain Case Comments] window for follow-up. Use “other conclusive verification” as verification source. Note: A statement from a chiropractor or any other health professional not described above cannot be accepted as proof of incapacity for Medi-Cal purposes. Reminder: Incapacity must be verified prior to approval of eligibility. [Refer to “Definitions,” page 60-1 for further information.]

25.4 Absent Parent [50213] 25.4.1

Definition of Absent Parent (A/P) Deprivation

Deprivation of parental support or care exists if there is continued absence of one or both parents from the home. Deprivation of absence links the children of the absent parent, the remaining parent or the nonparent caretaker relative, including the caretaker of children receiving PA.

25.4.2

Continued Absence

Continued absence shall constitute deprivation if the absence is both: 1. Of such a nature as to interrupt, terminate or preclude the parent's providing for the children any of the following: Revised: 11/16/07

Update # 2007-10

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• Maintenance, or • Physical care, or • Guidance AND 2. Of a known or indefinite duration which would preclude the parent's planning for the present support or care of the children.

25.4.3

Temporary Absence

Deprivation does not exist when the parent is absent from the home on a temporary basis, such as for: • • • • •

A visit. A trip. Current employment. Seeking prospective employment. Due solely to active duty in the uniformed services of the United States.

Note: Uniformed services include the Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanographic and Atmospheric Administration and Public Health Service of the United States.

25.4.4

Establishing A/P Deprivation

Absent Parent Deprivation will be established by client's statement on the Statement of Facts unless the EW has conflicting information. In the case of conflicting information, the client's statement shall be supported by one of the following: • Written statement from the absent parent. • Written statement from persons with prior knowledge of the family relationship. • The actions of the applicant, beneficiary or absent parent clearly indicate the physical absence of the other parent OR the interruption of or marked reduction in marital and family responsibilities. The above must be clearly documented on the [Case Comment] window in CalWIN. Update # 2007-10

Revised: 11/16/07

Medi-Cal Handbook

page 25-8 Medically Needy (MN) Medi-Cal • Other evidence that substantiates continued absence.

Joint Custody Deprivation based on continued absence may be established in joint custody cases as long as the child(ren) is not living with both parents at the same time. Periods of time spent in the home of the parent who is not the care- taker parent will be considered temporary absences. [Refer to “Definitions,” page 60-1.]

25.4.5

Who is Linked to A/P Deprivation

The following people are linked to Medi-Cal due to A/P deprivation of the child: • The child. • The parent/caretaker relative in the home. Note: If the parent in the home is married, and the spouse also has children from a prior union, then the separate children of each parent and both parents are linked due to A/P deprivation. The mutual children could be eligible as MI.

25.5 Unemployed Parent [50215] 25.5.1

Background

Effective November 26, 1996, U/P deprivation requires only that the PWE does not work 100 hours or more in a given month. Effective March 1, 2000, U/P deprivation requirements were expanded to include families with a PWE who works over 100 hours per month, if the family’s net non-exempt EARNED income is AT or BELOW 100% Federal Poverty Limit (FPL). Effective May 1, 2001, a State Plan Amendment was approved which further expanded U/P deprivation requirements to exempt all earned income of children in the family when determining whether the PWE is unemployed even though he/she is working 100 hours or more.

Revised: 11/16/07

Update # 2007-10

Medi-Cal Handbook

25.5.2

page 25-9 Medically Needy (MN) Medi-Cal

Rule

Deprivation of parental support or care exists if a parent with whom the child lives meets the conditions of an Unemployed Parent (U/P).

25.5.3

Conditions of an Unemployed Parent

The Unemployed Parent (U/P) must be determined as the Principal Wage Earner (PWE) AND meet ONE of the following conditions for U/P deprivation to exist: 1. Is working under 100 hours per month. This includes when the PWE is: • Not working, or • Working less than 100 hours per month, or • Employed on an intermittent basis more than 100 hours per month and the hours in excess of 100 hours are of a “temporary nature”. Note: “Temporary nature” is shown if the parent was under the 100 hour standard for the two prior calendar months and is expected to be under the standard during the next month. OR 2. The total net non-exempt EARNED income of the parents or the parent and his/her spouse is AT or BELOW 100% of the Federal Poverty Level (U/P Income Test).

25.5.4

Principal Wage Earner (PWE)

EWs must first establish which parent is the Principal Wage Earner (PWE) in order to determine if U/P deprivation exists. The PWE is the parent who has earned the greater amount of income in the 24-month period immediately preceding either: • The month of application, reapplication or restoration, or • The date that a family's circumstances have changed in such a way as to meet the U/P deprivation requirements.

Update # 2007-10

Revised: 11/16/07

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Note: If both parents qualify as the PWE and have earned an identical amount of income (or no income) in the 24-month period, the EW in consultation with the parents must designate which parent is the PWE. Once the PWE has been determined, this parent continues to be the PWE for each consecutive month, even if the other parent has earnings in the last two years.

EXAMPLES Incapacitated at Time of Application: A family applies for Medi-Cal on December 1st and deprivation is based on the incapacity of the father. In March, the EW learns that the father is no longer incapacitated as of March 10th. A U/P determination must be completed in March. A determination of who is the PWE begins on the date that the deprivation changed (March 10th). It is not based on the month of the original application. Unemployed Parent Becomes Incapacitated: A family is determined eligible for Medi-Cal based on U/P deprivation at the point of application. Four months later the PWE becomes incapacitated due to a broken arm. The deprivation must be changed to incapacity. However, when the incapacitated parent recovers, the deprivation is changed back to U/P. The PWE determination still exists based on the earlier U/P determination. CalWORKs U/P Case Becomes Medi-Cal Only Case: The father is determined to be the Principal Earner (PE) in a CalWORKs U/P case. His wife begins to work and the family becomes financially ineligible for CalWORKs due to excess earnings. CalWORKS is discontinued and ongoing Medi-Cal eligibility is explored. U/P deprivation still exists and does NOT need to be reestablished since the PWE is still considered an unemployed parent. Therefore, the family is still linked to the Section 1931(b) program. Eligibility for Section 1931(b) is determined first. If the family is not eligible, TMC is explored. Reapplication for Medi-Cal: If there has been more than a one month break-in-aid, the PWE must be reestablished.

25.5.5

SC 1707 or MC 210 S-W

CalWIN determines the PWE if employment history for both parents is entered. CalWIN also determines the U/P deprivation. If the client is having an interactive interview at Intake, it is not necessary for them to complete the SC 1707 or MC 210 S-W. The EW will just obtain that information and enter it in CalWIN. For mail-in applications, the worker can first try to obtain the employment history from the client over the phone, and enter it in CalWIN and document in the [Maintain Case Comments] window how the information was obtained. If the worker is unable to Revised: 11/16/07

Update # 2007-10

Medi-Cal Handbook

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contact the client to get the information, then the SC 1707 or MC 210 S-W form must be sent to the client to gather the data for CalWIN to determine the PWE. Unless there was a break in aid or only one parent was in the home at intake and the A/P has now returned, a new PWE determination does not need to be done at redetermination. The SC 1707 or MC 210 S-W can be used to determine: • Which parent is the principal wage earner (PWE) • U/P deprivation when both parents are in the home. Note: If the PWE works 100 hours or more a month, the “Unemployed Parent Worksheet” (MC 337) may be used to determine U/P deprivation. Only one signature is required on this form, usually the applicant's. Determination of the PWE is not required when there is other linkage, such as absent parent.

25.5.6

U/P Income Test

U/P deprivation exists if the total net non-exempt EARNED income of the parents or the parent and his/her spouse is AT or BELOW 100% of FPL (U/P Income Test). Sneede rules do NOT apply to the U/P Income Test. The U/P Income Test applies to AFDC-MN and Section 1931(b).

Countable Earned Income Only the net non-exempt EARNED income of the parents or the parent and the parent’s spouse is counted. Earned Income includes income received from: • • • •

Employment, Earned Income In Kind State Disability Insurance (SDI), and Temporary Workers Compensation (TWC).

DO NOT count the EARNED income of a parent who receives Public Assistance (PA) or Other PA or who has the option not to be aided and is not in the MFBU. DO NOT include these persons in the family size to determine 100% of FPL.

Update # 2007-10

Revised: 11/16/07

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Allowable Deductions The following deductions are allowed when determining net non-exempt EARNED income for U/P deprivation: • • • • • •

$90 Standard Work Expense (SWE) $65 and 1/2 if there is an aged, blind or disabled family member in the MFBU Child Care Deduction Court-Ordered Child/Spousal Support Allocations to PA Members Allocations to Excluded Children.

Note: Health Insurance Premiums are NOT allowable deductions.

Procedure Follow the steps below to determine the net non-exempt income: Step

Action

Calculation

1.

Subtract $90 from the gross non-exempt EARNINGS of the PWE and his/her spouse.

Earnings of:

(Use the $65 + 1/2 and the unused $20 rather than the $90 if there is an ABD person in the MN determination). 2. 3.

Add each person’s net EARNINGS together to get the total family countable EARNED INCOME.

PWE 2nd Adult

$_ __ - 90 = $_____ $____ - 90 = $_____

Countable Earnings = $_______

Determine total allowable deductions, including: • • • •

Child Care Expenses, Court-Ordered Child/Spousal Support, Allocations to PA members, and Allocations to excluded children.

$_______ + $_______ + $_______ + $_______ Total Deductions

4.

= $_______

Subtract the allowable deductions to get the family’s Total Net Non-exempt EARNED Income

Step 2 - Step 3 = $______

5.

Determine 100% of FPL for the appropriate family size.

100% of FPL

6.

Compare Line 4 to Line 5. Is the Total Net Non-Exempt EARNED Income of the Parents AT or BELOW 100% of FPL?

__ Yes; U/P Deprivation Exists.

Revised: 11/16/07

Update # 2007-10

= $______

__ No; No U/P Deprivation.

Medi-Cal Handbook

25.5.7

page 25-13 Medically Needy (MN) Medi-Cal

Who is Linked to U/P Deprivation

Unemployed Parent (U/P) deprivation links the: • Child(ren) of the unemployed parent, • Unemployed parent, and • Second parent in the home. Note: The stepparent can be treated as an “essential person” in the Section 1931(b) program. [Refer to “MFBUs Containing Stepparents,” page 23-15.]

25.6 ABD-MN Linkage 25.6.1

General

The following persons may be eligible for Medi-Cal under the ABD-MN programs: • An Aged Person. • A Blind Person. • A Disabled Person. Reminder: A child may be blind or disabled.

25.6.2

Aged Persons [50221]

Individuals are aged if they are 65 years of age or older. Persons are considered to be 65 years of age on the first day of the month in which they reach 65.

25.6.3

Blind [50219]

Persons shall be considered blind if there has been a medical determination that they have either of the following conditions: • Central visual acuity of no more than 20/200 with best possible correction, or • Tunnel vision with a limited visual field of 20 degrees or less.

Update # 2007-10

Revised: 11/16/07

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Determination of blindness must be made by DAPD prior to approval of Medi-Cal eligibility under this program. [Refer to “DDSD — Disability Referral Criteria,” page 27-1 for Presumptive Disability Criteria.] Note: If client has previously been determined to be disabled or is over 65, DAPD will not do a blindness evaluation unless client is either: • Employed. (Employed blind persons are eligible to an additional income deduction per 50551.4.) OR • A potential Pickle Person. (Blind persons have a higher SSI/SSP payment level to be used on the Pickle Financial Eligibility Worksheets, DHS 7021, Part I, and Part VI, Line 1.) Note this on MC 221. [Refer to “DDSD — Disability Referral Criteria,” page 27-1.]

25.6.4

Disabled Persons [50167, 50223]

1. Persons 18 years of age or older are disabled if they are either of the following: a. Unable to engage in any substantial gainful activity because of a physical or mental impairment which: (1) Can be expected to result in death, or (2) Has lasted or can be expected to last for a continuous period of not less than 12 months. b. Engaging in substantial gainful activity and meet both of the following conditions: (1) Were eligible for SSI/SSP but became ineligible due to engagement in substantial gainful activity, and (2) Continue to suffer from the physical or mental impairment which was the basis of the disability determination. 2. Children who are under 18 years of age is considered disabled if they have any medically determinable physical or mental impairment of comparable severity to that which would make an adult disabled. Revised: 11/16/07

Update # 2007-10

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3. Determination of disability may be made by DAPD prior to approval under this program. Note: [Refer to “DDSD — Disability Referral Criteria,” page 27-1 for procedures regarding Blindness or Disability determination and when Disability must be reverified.]

25.7 Linkage Charts

AFDC-MN LINKAGE [Section 50205 and MEPM 50) A child is deprived of parental support if any of the following factors exists. If there is more than one deprivation factor, linkage to AFDC may be established on the basis of any deprivation listed below. The EW shall explain the advantages and disadvantages of each. The deprivation shall be the choice of the parent/caretaker. 1. DEATH

2. INCAPACITY

[Section 50209]

[Section 50211]

A child whose parent(s) are deceased may be considered deprived of parental support. This deprivation factor is to be used for the:

A child whose parent(s) are physically or mentally incapacitated by the rules of this section are considered deprived. Linkage based on this factor is for the;:

a. Child(ren) of deceased parent.

a. Children of the incapacitated parent.

b. Surviving parent. c. Relative caretaker. [Refer to “AFDC-MN — Linkage in General [50205],” page 25-1]

Update # 2007-10

b. Incapacitated parent. c. Spouse of the incapacitated parent, stepparent or the second parent.

Revised: 11/16/07

Medi-Cal Handbook

page 25-16 Medically Needy (MN) Medi-Cal AFDC-MN LINKAGE [Section 50205 and MEPM 50) 3. ABSENCE

4. UNEMPLOYMENT

[Section 50213]

[Section 50215]

If one or both parents are considered out of the child’s home, by the rules of this section, the child is considered deprived. Linkage is for the:

If a parent meets ALL conditions of this section, linkage is established for:

a. Child of absent parent.

b. Unemployed parent.

b. Parent in the home.

c. Second parent.

c. Relative caretaker.[Refer to “AFDC-MN — Linkage in General [50205],” page 25-1]

NOTE: The spouse/stepparent cannot be linked.

a. Child(ren) of the unemployed parent.

NOTE: When absence and/or death is the ONLY deprivation factor and spouses each have children by a prior union, both parents are linked. ALL FAMILY MEMBERS LIVING IN THE HOME EXCEPT INELIGIBLE OR EXCLUDED CHILDREN MUST BECONSIDERED IN DETERMINING AFDC LINKAGE.

INCAPACITY vs. DISABILITY Medically Needy Program [Section 50203b] A person who meets the conditions of more than one of the following categories shall have eligibility determined on the basis of the category listed first unless the person requests otherwise: 1. Blindness, as defined in Section 50219. 2. Age, as defined in Section 50221. 3. Disability, as defined in Section 50223. 4. Linkage to AFDC, as defined in Section 50205. INCAPACITY (AFDC LINKAGE)

Revised: 11/16/07

DISABILITY/BLINDNESS (ABD LINKAGE)

Update # 2007-10

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INCAPACITY vs. DISABILITY [Section 50211]

[Sections 50219 and 50223]

The parent who meets this criteria (impairment of at least 30 days that reduces ability to support or care for child) can be linked to AFDC.

The person who meets this criteria can be ABD-Linked.

Depending upon the severity of the incapacity, a worker may consider pursuing ABD-Linkage. ABD-Linkage is almost always advantageous to the client, because of the more liberal income deductions in the ABD-MN Program.

The criteria for disability is more restrictive than incapacity and therefore also meets the AFDC deprivation requirements. A parent who is ABD-Linked by reason of disability or blindness is considered incapacitated for purposes of linking other eligible family members to AFDC. NOTE: AGE (65 years or older) is not considered incapacitating and cannot be used as a deprivation factor.

Figure: To Determine AFDC-U Linkage

1. Is deprivation due to unemployment--------------No---------------No linkage of the PWE? | Yes | 2. Has PWE worked less Is the total family than 100 hours in net non-exempt EARNED the month? ------------No---- income AT or BELOW ---------No-----No linkage | 100% of FPL? | | Yes Yes | | 3. AFDC-U linkage is established.

Update # 2007-10

Revised: 11/16/07

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ABD LINKAGE BLINDNESS - [Section 50219]

AGE - [Section 50221]

A person is considered to be blind when there is a medical determination that either of the following conditions exist:

Persons age 65 or older are considered linked on the first day of the month in which they reach 65.

1. Central visual acuity of no more than 20/200 with correction. 2. Tunnel vision, which is a limited field of 20 degrees or less. DISABILITY - [Section 50223] The definition of disability in the ABD Medically Needy Program is the same as that used in SSA Disability and SSI Disability of the Social Security Act. A medically determined physical or mental disability exists for: Persons over 18 who are unable to engage in substantial gainful employment and the impairment: 1. Can be expected to result in death, OR

Persons 18 or under when the impairment is of comparable severity to that which would make an adult disabled.

2. Has lasted continuously for 1 year, OR 3. Can be expected to last continuously for 1 year.

25.8 Cash/Medi-Cal Differences To Keep In Mind Between CalWORKs eligibility and AFDC-linked Medi-Cal [Section 1931(b) and AFDC-MN] there are a number of distinctions in budget-unit and linkage determination that are summarized and listed here. The list is not totally inclusive, but is intended to be a reminder of some of the differences that may be particularly confusing to the generic worker or the Medi-Cal worker with a cash background. Note: Cash eligible requirements are not listed.

Revised: 11/16/07

Update # 2007-10

Medi-Cal Handbook

25.8.1

page 25-19 Medically Needy (MN) Medi-Cal

Linkage to Medi-Cal when the Only Child is on SSI/SSP

In Medi-Cal, all family members living in the home are considered in determining linkage except the ineligible or excluded child. (The PA person is not considered to be “excluded.” He is simply “not included.”) If the only child in the home is an SSI recipient and there is also deprivation deceased parent, incap. parent, absent parent or federal U-Parent, there is AFDC linkage for the child's parent(s). A nonparent caretaker relative may also have AFDC linkage to a child who is receiving SSI. Example: A child is in Agnews pending SSI and has absent parent deprivation. Mother applies for Medi-Cal for herself and the child. In this situation, the child is considered to be in the home as long as the parent continues to exercise care and control of the child. Parental care and control continues to exist until and if the Court removes this responsibility from the parent(s) or the parent(s) voluntarily relinquishes it.

25.8.2

No Work Registration Requirement

Work registration is never required in Medi-Cal.

25.8.3

Medi-Cal Family Budget Unit (MFBU)

Unmarried Minor Parent in the Home In Medi-Cal, three generation household cannot be in the same MFBU as sometimes occurs in CalWORKs. Two separate cases must be set up. Only parents and their children can be eligible in the MFBU. The grandchildren must be in their own MFBU with their parent(s) as ineligible member(s).

Caretaker Relative In Medi-Cal, the nonparent relative caretaker and the child for whom he/she is caring must be in the same case in CalWIN even if he/she has his/her own linkage (ABD). If he/she does not request Medi-Cal, he/she is still included in the MFBU but indicate “not requesting aid.”

Update # 2007-10

Revised: 11/16/07

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25.8.4

Linkage When Parents are Sponsored Aliens

When parents are admitted to the U.S. as sponsored aliens and their needs are met by the sponsor's deemed income, the children may be admitted as refugees and therefore do not have sponsored alien requirements to meet after arrival. The children can receive CalWORKs with U/P deprivation. The parents are not eligible for CalWORKs but they are linked to Section 1931(b) or AFDC-MN. Note: For Medi-Cal-only cases, sponsor’s income and resources are not explored or counted.

25.9 Examples of Linkage 25.9.1

Death

Example: An unmarried couple have two children in common. The father dies and the mother is left with the two children in the home. Is there deprivation? Yes, death of an unmarried parent constitutes deprivation. The mother and children are linked. Example: A husband and wife have one child. The husband goes on a boating trip and is presumed lost at sea. He has been missing over 30 days, and the search is called off. Is there deprivation? Yes. The preponderance of the evidence establishes the death of a parent; however, it would also be correct to instead base deprivation on continued absence. The mother and child are linked. Example: A married couple adopted four children. The wife dies in an auto accident. Is there deprivation? Yes. There is no distinction between adoptive and natural parents in determining deprivation. Revised: 11/16/07

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Example: A woman with a child remarries. Her husband does not adopt the child. The husband dies. Is there deprivation? Yes, but not due to the death of the stepfather. Deprivation would be based on the child's natural father's death or absence. Both mother and child are linked.

25.9.2

Incapacity

Example: Under what circumstances can pregnancy have AFDC-MN linkage based on incapacity? When the conditions of Sections 50167(a)(2) and 50211 exist. That is, when a physician, etc., documents that incapacity exists and gives the expected duration of the condition. The receipt of State Disability Insurance for the automatic six week period following delivery does not establish incapacity. Example: If a pregnant woman has verification from her doctor that she has a condition that affects her pregnancy such as diabetes, high blood pressure, or drug addiction, is she considered incapacitated even though she has no work history and the only child is an unborn? Yes, her condition reduces her ability to care for the child even though the child is an unborn. If her condition did not affect her pregnancy, i.e., broken leg, she could be aided as a Medically Indigent woman. Her husband or father of the unborn would not be linked. Example: Mr. D. and his child from a former marriage both receive SSI on the basis of disability. Mrs. D. applies for Medi-Cal. Is she linked? Yes. Even though Mr. D. and his child are not in the MFBU as eligible persons, deprivation exists for the child on the basis of his father's incapacity. The spouse of the incapacitated parent is also linked. Deeming requirements apply. Example: A husband and wife have two children. The husband was a computer programmer. As a result of an auto accident, he suffered brain damage. The damage did not prevent him from performing the technical aspect of his job; however, it altered his personality and behavioral patterns to the point that he could no longer perform his job. Because of this disorder, other attempts to Update # 2007-10

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secure employment have been futile. Is there deprivation? Yes. A verified mental problem which prevents one from securing and maintaining employment would justify deprivation based on incapacity. The husband, wife and two children are linked. Example: An unmarried couple have two children. The mother is injured in an auto accident. Expected recovery time is six months. Is there deprivation? Yes. The deficiency will last longer than 30 days and will substantially reduce the parent's ability to care for her children. Both parents and the children are linked by incapacity. Example: Mrs. J. is injured in an auto accident; recovery will take about three months. She is an undocumented alien. Her husband and child are citizens. Is there deprivation? Yes. All family members are linked. Example: If a parent is incapacitated, must the EW also make a referral to DAPD? If an incapacitated parent has a condition that will last more than 12 months and/or is expected to result in death, it is recommended that the EW make a referral to DAPD because an aged, blind or disabled (ABD) person receives certain income deductions that are not otherwise available. Also, ABD persons are treated differently if in long term care for MFBU purposes.

25.9.3

Absence

Example: Mrs. A. applies for Medi-Cal for herself and two grandchildren. She is caring for the children while the parents are away. Their father is job-hunting out of state and their mother is visiting relatives. They expect to be gone six or eight weeks. Is there deprivation? Not under absence. The parents are temporarily absent from the home and thus considered “family members living in the home.” They may apply for the children.

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Example: A divorced husband and wife have two children. The husband has the children one month and the wife has the children the next month (joint custody). Is there deprivation? Yes. However, two cases may be established if both parents are separately eligible. Each case will have a parent and two children included but only one case must be active at any one time for purposes of AFDC linkage. The children are treated as if they were excluded children in the case belonging to the parent with whom they are not residing in that month. If only one parent is eligible, the children will be eligible only the time they are with the eligible parent. Example: A separated couple has one child. The father provides for the child every month: medical insurance coverage, financial support, and since he has the child every weekend, he provides physical care and guidance. Is there deprivation? Yes. Although it appears that the husband is providing all needs necessary to the support and guidance of the child, he remains out of the home and his absence is of an indefinite duration. The mother and child are linked.

25.9.4

Unemployment

Example: May counties accept the applicant's statement regarding earnings over the previous 24-month period? Yes. The applicant must submit statements regarding both spouses' earnings. Example: If both spouses earned the same amount during the previous 24 months, who would be the principal wage earner? Either parent.

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Example: Is a family linked to AFDC if the unemployed PWE earner is 65? Yes, as long as the conditions for U-parent deprivation exist. “Conditions of an Unemployed Parent,” page 25-9 EDD registration is not a requirement in Medi-Cal. Example: Mr. W. meets all conditions of a “U” parent. He and his wife have refused to apply for a Social Security Number for their newborn child. Is there AFDC linkage? No. An ineligible child cannot establish AFDC-MN linkage. Example: Mrs. T. is the PWE and meets all conditions of a “U” parent. She only wants Medi-Cal for herself and husband. Their only child has bank accounts that would put them over the property limit. She wants to exclude him. Would there be AFDC linkage? No. In order for deprivation to exist, there must be a deprived child. An excluded child may not be considered in determining linkage. Example: Do we re-assess PWE at annual reinvestigation? No. The “24-month period prior to the month of application” determination continues as long as there is no break in the “U” program. (Going from a CalWORKS case to a Section 1931(b)/AFDC-MN case - or visa versa - does not constitute a break.) Examples of breaks are: 1. AFDC-MN U/P case changes to an MI case. 2. Discontinuance of 1 month or more from cash or Medi-Cal. 3. AFDC-MN U/P case changes to deprivation based on Absence. Following a break in Medi-Cal based on U/P deprivation, a new 24-month period is established when eligibility to that program is reassessed. (Re-assessment of eligibility is construed as “reapplication”.)

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Example: Mr. and Mrs. A and their 19 year old child apply for Medi-Cal in May 2000. Mr. A is unemployed and Mrs. A is working full time. The parents declare that Mr. A earned $30,000 during the period April 1998 through April 2000 while Mrs. A earned $26,000 during this same period. Therefore, Mr. A is identified as the PWE and Medi-Cal is granted under the AFDC-MN U/P program. In August 2000, Mr. A becomes employed and the family is transferred to the MI program. In October 2000, Mr. A is laid off from his job. In determining eligibility effective October for the AFDC-MN unemployed parent category, the county must evaluate the earnings of each parent during the period September 1998 through September 2000. In this instance Mrs. A is the PWE with income of $33,000 during this period while Mr. A's earnings were only $31,000. Mrs. A is employed and the net non-exempt EARNED income of the parents is over 100% of FPL for a family of 3, so deprivation does not exist.

25.10 CalWORKs Case, Family Member Potentially Eligible for Medi-Cal There are several situations that occur in a CalWORKs caseload which require the EW to explore eligibility for Medi-Cal only when a family member is not eligible for, or not receiving a cash grant.

25.10.1

CalWORKs Case Active Certain Family Members Ineligible or Excluded

The CalWORKs case is ongoing; however, there are certain family member(s) who are either ineligible or choose not to be in the Assistance Unit (AU). The EW shall explore Medi-Cal eligibility when: • Discontinuing an 18-year-old, or any child, from CalWORKs. • Persons are in the “Family”, but excluded from the CalWORKs AU because they are undocumented or have an unexpired temporary visa.

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Note: These persons may be automatically deemed eligible for Restricted Medi-Cal (emergency care and pregnancy services) under the Section 1931(b) program. • The caretaker relative is not eligible for CalWORKS, or chooses not to receive CalWORKs. He/She may have AFDC linkage for Section 1931(b) or AFDC-MN. • A stepparent with no mutual child or deprived child(ren) of his/her own may be linked to AFDC-MN if the parent is incapacitated. • Parents/child(ren) who are excluded from the AU for noncooperation with CalWORKs requirements may be automatically deemed eligible for Medi-Cal under the Section 1931(b) program. (e.g., CWES Sanctions, Time Limits) Note: Application for unconditionally available income is a requirement for both CalWORKs and Medi-Cal. • Persons who are in the “Family” who are not receiving a cash grant. • Persons who are in the CalWORKs household who are under age 21 may be eligible for Section 1931(b), AFDC-MN, or as Medically Indigent (if there is no deprivation).

25.10.2

Entire CalWORKs Case to be Discontinued

When an entire CalWORKs case is being discontinued, continuing Medi-Cal eligibility must be explored under the Section 1931(b) program. If the CalWORKs case is discontinued for a reason that does not impact Medi-Cal eligibility (e.g., failure to return QR7,) all members must be transferred to Section 1931(b). If Section 1931(b) eligibility cannot be established, continuing Medi-Cal eligibility must be explored for the following programs: • Four Month Continuing Medi-Cal, or • Transitional Medi-Cal (TMC), or • Edwards v Myers.

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Note: If there is enough information and the required forms are on file, establish continuing Medi-Cal. If the reason for the CalWORKs discontinuance is also a valid reason to discontinue Medi-Cal, a separate/appropriate Medi-Cal discontinuance NOA must be sent.

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