May 25, 2010

CalWORKs PROGRAM GUIDE

SPECIAL NOTICE

10-06

 

Subject

REVISED CalWORKs TRANSITIONAL MEDI-CAL FORM, CW 103

 

Reference

All County Information Notice No. I-08-10 and All County Letter No. 99-18.

 

Effective Date

May 25, 2010

 

Purpose

The purpose of this CalWORKs Special Notice is to provide staff with the newly revised CalWORKs Transitional Medi-Cal Form, CW 103.

 

Background

California families who are no longer eligible to CalWORKs (cash aid) benefits because of earnings from work are eligible to receive up to 12 months of Transitional Medi-Cal (TMC).

 

Current legislation requires that CalWORKs recipients be informed of the Transitional Medi-Cal (TMC) program upon termination from cash aid.

 

The CW 103 Transitional Medi-Cal Notice is informational and multilingual with an attached form for families to request Extended or Transitional Medi-Cal.

 

The CalWORKs Transitional Medi-Cal Form, CW 103, was revised by the state due to the elimination of the state-only second year of Transitional Medi-Cal, per Assembly Bill 1762 (Chapter 230, Statutes of 2003). 

 

HSS Actions

Staff are required to send the language appropriate CW 103 informing notice and form upon termination of CalWORKs cash aid due to earnings from work.

 

Both the English and Spanish versions of the CW 103 have been uploaded to The Xerox Print Center for use.

 

Staff may order the form in English or Spanish as shelf stock from The Xerox Print Center or they may obtain individual copies of the form directly from the CalWIN Intranet  web page at:

 

http://cosda428p/calwin/Home/ClientCorrespondence/tabid/173/Default.aspx

 

In addition to the English and Spanish versions of the CW 103, Russian, Chinese, Vietnamese and Cambodian translations of the form have been uploaded to the CalWIN Intranet for use.  Staff will be notified if the state translates the CW 103 into additional languages.

 

Program Impact

There is no impact to either the Food Stamp or Medi-Cal Programs.

 

Automation Impact

None.

 

ACCESS Impact

ACCESS Agents will notify households discontinued from cash aid of TMC eligibility. Agents will send the appropriate language CW 103 informing notice and form upon termination of CalWORKs cash aid due to earnings from work.

 

Imaging Impact

Due to the fact the CW 103 form requires a client signature; workers will image the signed form with the 16-143 Medical Documentation Template to ensure Transitional Medi-Cal workers can access the document.

 

Operations Impact

None.

 

Forms Impact

The CW 103 Transitional Medi-Cal form has not been uploaded to CalWIN Production by the consortium therefore, it is only available as shelf stock from The Xerox Print Center or from the CalWIN Intranet/Home Page/ Client Correspondence/CalWORKs - Shelf Stock.

 

http://cosda428p/calwin/Home/ClientCorrespondence/tabid/173/Default.aspx .

 

Quality Assurance (QA) Impact

Quality Assurance will cite the appropriate error when the instructions in this Special Notice have not been followed.

 

Assistant Deputy Director

 

Original signed 5/25/10

 

 

 

SYLVIA MELENA, Assistant Deputy Director

Self-Sufficiency Programs

Strategic Planning & Operational Support