Article 13 Section 04 Changes to Share Of Cost (SOC)

 

Table of Contents

 

Title

PG Cite

General

13.04.01A

SOC Increases

13.04.02

Changes Reported in a Timely Manner

13.04.02A

Changes Not Reported in a Timely Manner

13.04.02B

Changes Reported Before The 15th

13.04.02C

Changes Reported After The 15th

13.04.02D

SOC Decrease

13.04.03

Change Reported Within 30 Calendar Days

13.04.03A

Change Not Reported Within 30 Calendar Days

13.04.03B

Married Couples With A SOC

13.04.04

Both Spouses are on CMS with a SOC

13.04.04A

One Spouse on CMS with a SOC and the Other Spouse on Medi-Cal with SOC

13.04.04B

SOC Verifications Not Received

13.04.04C

 

 

13.04.01 Changes to SOC

 

13.04.01A
General

Changes in income may require an adjustment to the monthly SOC. The SOC may need to be increased or decreased according to income level.

 

13.04.02 SOC Increase

 

13.04.02A Change Reported In A Timely Manner

When a change in income or other circumstances, which results in an increase in the share-of-cost, is reported timely (Refer to 02.01) by the beneficiary, the worker shall change the share-of-cost either in a future month or immediately.

 

Future Re-computation

 

If a 10-day notice…

Then the worker will recompute the SOC for the…

can be given,

month following the month that the  change was reported.

cannot be given,

second month following the month in which the change was reported.

 

Immediate Re-computation

If the increase is due to the voluntary inclusion of a family member who has income, which results in a SOC increase for the household, the household’s SOC cannot be increased without timely notice of action.

 

The worker will recompute the SOC immediately and follow the appropriate steps detailed below:

a)    If the individual being added to the case will be included in the MFBU with other household members, the individual will receive benefits through a separate FBU for the first month of aid or until a 10 day notice can be given to increase the household’s SOC.  When timely notice can be given, the individual will be discontinued from his/her separate FBU and added to the household’s MFBU.

 

b)    If the individual being added to the case will be in a separate FBU from other household members, the individual will receive benefits through that FBU with the recomputed SOC.

 

c)    Issue a NOA approving benefits for the newly added family member with the correct SOC for that individual.  Issue a second NOA effective the first of the following month indicating the increased SOC for the entire MFBU (as long as timely notice can be given).

 

13.04.02B Change Not Reported In A Timely Manner

When a change in income or other circumstances, which results in an increased SOC, is not reported timely, the worker will:

·   Increase the SOC in the month following the month in which the change was reported, or the first of the second month following the month in  which the change was reported, if 10-day notice cannot be given; and

·   Evaluate for a potential overpayment (Refer to 11.04) beginning the month following the month the change should have been reported.

 

13.04.02C
Change Reported Before the 15th

When a change in income or other circumstances is reported before the 15th of the month, which results in an increase to the SOC, the worker will follow the actions in the table below:

 

Step

Action

1

Request all verifications needed to accurately calculate the change by sending the CMS-34 Informing Letter.

2

Recompute the CMS budget and the CMS Hardship budget once all verifications are received.

3

Increase the SOC effective the following month that the change was reported and send the CMS-39S NOA notifying the individual of the change.  This NOA is part of the case record.

4

Notify the ASO of the SOC change via CMS-4 Registration Information form.  The CMS-4 must include the new SOC amount and the effective date.  The CMS-4 is part of the case record.

5

Note in the comment section of the CMS-4 the new SOC amount and the effective date.

 

MPG Letter #662 (2/09)

 

13.04.02D
Change Reported
After the 15th

When a change in income or other circumstances is reported after the 15th of the month, which results in an increase to the SOC, the worker will follow the actions in the table below:

 

Step

Action

1

Request all verifications needed to accurately calculate the change by sending the CMS-34.

2

Recompute the CMS budget and the CMS Hardship budget when all verifications are received.

3

Increase the SOC effective the second month following the month in which the change was reported and send the CMS-39S NOA notifying the individual of the change.  This NOA is part of the case record.

4

Notify the ASO of the SOC change via CMS-4 form.  The CMS-4 must include the new SOC amount and the effective date.  The CMS-4 is part of the case record.

5

Note in the comment section of the CMS-4 the new SOC amount and the effective date.

 

 

13.04.03 SOC Decrease

 

13.04.03A
Change Reported Within 30 Calendar Days

When a change in income or other circumstances is reported, which results in a decrease to the SOC and the change was reported within 30 calendar days of the change, the worker will follow the actions in the table below and change the SOC as follows:

 

Step

Action

1

Request all verifications needed to accurately calculate the change by sending the CMS-34.

2

Recompute the CMS budget and the CMS Hardship budget when all verifications are received.

3

Decrease the SOC for the month that the change has occurred and send the CMS-39S NOA notifying the individual of the change. This NOA is part of the case record.

4

Notify the ASO of the SOC change via CMS-4 form.  The CMS-4 must include the new SOC amount and the effective date.  The CMS-4 is part of the case record.

5

Note in the comment section of the CMS-4 the new SOC amount and the effective date.

 

 

13.04.03B
Change Not Reported Within 30 Calendar Days

If the change is not reported within 30 calendar days of the change, the worker will follow the actions in the table below:

 

Step

Action

1

Request all verifications needed to accurately calculate the change by sending the CMS-34.

2

Recompute the CMS budget and the CMS Hardship budget when all verifications are received.

3

Decrease the SOC for the month following the month in which the change was reported and send the CMS-39S NOA notifying the individual of the change.  This NOA is part of the case record.

4

Do not change the SOC amount for the month reported unless the beneficiary had good cause for failure to report within 30 calendar days of the change.

5

Notify ASO of change via CMS-4 form. The CMS-4 must include the new SOC amount and the effective date.  The CMS-4 is part of the case record.

6

Note in the comment section of the CMS-4 the reason for not changing the SOC in the current month and the new SOC amount and the effective date.

 

NOTE:  Changes to the budget, which cause a decrease to the monthly SOC, will change the SOC in the current month if the change is reported with 30 calendar days of the change.  The worker must send the CMS-39S NOA notifying the individual of the change.

 

13.04.04 Married Couples with a SOC

 

13.04.04A
Both Spouses on CMS with a SOC

·   Both spouses must read and sign the SOC Process Information Sheet (CMS-111) which informs them of their SOC payment responsibilities.  

·   The SOC amount shall be applied to the couple.

 

The worker must take the following steps to link and apply the SOC amount to the married couple in IDX:

 

Step

Action

1

Complete CMS-4 form and state the SOC amount for the CFBU.  Note on the “comment Line” that this is a married couple with a SOC and both spouses Social security Numbers.

 

(EXAMPLE:  Married couple both on CMS w/SOC Identified; SSN xxx-xx-xxxx and SSN xxx-xx-xxxx.)

2

Scan the CMS-4 form into both spouse’s case records in the CMS IT System.

3

Send the completed CMS-4 to the ASO at MS 0557B.

  

 

13.04.04B
One Spouse on CMS with a SOC the other on Medi-Cal with SOC

·   Both spouses must read and sign the CMS-111 which informs them of their SOC payment responsibilities and gives the County authorization to add the Medi-Cal spouse’s information to IDX for billing, if needed.

·   The entire CMS SOC amount shall be applied to the CMS spouse.

·   The CMS individual shall be advised that monies spent to meet the Medi-Cal spouse’s SOC may be applied to reduce the CMS SOC amount using CMS rates, as long as the services are within CMS scope of services.

·   It is the CMS patient’s responsibility to provide the County (ASO) with an itemized statement and proof of the amount paid towards the MC SOC amount along with their CMS SOC payment statement.

·   The ASO has been instructed to forward all statements received for the Medi-Cal SOC payments to HCPA.  HCPA  will:

o  Review MEDS for verification of that the Medi-Cal SOC has been met; and

o Send the statement back to ASO for processing.

 

The worker must take the following steps to identify that this is a married couple, one on CMS with a SOC and the other on Medi-Cal with a SOC, in order for the paid Medi-Cal SOC amount to be applied to the CMS spouse in IDX:

 

Step

Action

1

Verify that the CMS-111 has been signed by the applicant and the spouse.

2

Complete CMS-4 form and state the SOC amount for the CFBU.  Note on the comment Line “Married couple with a CMS and Medi-Cal SOC”.

 

(EXAMPLE:  “Married couple w/CMS & Medi-Cal SOC identified; Spouse on Medi-Cal.)

3

The CMS-4 is part of the case record.

4

Send the completed CMS-4 to the ASO at mail stop 0557-B.

  

 

13.04.04C
SOC Verification Not Received

When verifications are not received within the first 10 days, the worker sends another CMS-34 giving the beneficiary an additional 10 days to comply.  If the verifications are not received after the extended 10 days, there are no changes to the CMS budget.  The worker must note in case comments no verifications received, no changes made and the SOC remains the same.

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