Article 3 Section 1 – County of Responsibility

 

Table of Contents

 

TITLE

MPG CITE

Overview

03.01.01

Family Composition

·   Persons With a Family

·   Persons Without a Family

03.01.02

Out-of-Home Placement

·   Public Agency/Government Representative

·   Private Agency/State Employed Person

·   Persons Placed in State Hospitals

·   Placement in Long Term Care after Release from a State Hospital

·   Long-Term Care – Incompetent/Incapacitated Individuals

03.01.03

General Situations

·   Public Assistance

·   Deceased Persons

·   Persons Absent from the State

·   Courtesy Applications

·   Persons Under 21 Years of Age

03.01.04

   

 

03.01.01 County of Responsibility

 

A.
Overview

The procedures contained in this section are administrative guidelines provided by the Department of Health Care Services (DHCS) to county staff to process Medi-Cal applications and to ensure that benefits and services remain accessible to applicants, beneficiaries, and representatives acting on behalf of the applicants/beneficiaries.  The objective of these procedures is to provide counties with information to administer the Medi-Cal program in a coordinated and efficient manner within the state and grant benefits promptly.

 

In resolving County of Responsibility issues, staff shall consider criteria such as:

 

·   The age of the applicant/beneficiary and his/her representative;

·   The physical and mental condition of the applicant/beneficiary;

·   The travel distance of the applicant/beneficiary and his/her representative;

·   The possible delay in the processing of the application and eligibility determination that may create an undue hardship for the applicant/beneficiary and/or his/her representative

MEM

PROC. 3B

 

03.01.02 Family Composition

 

A.
Persons with a Family

For individuals whose eligibility is determined as part of a family or based on family income, the County of Responsibility is one of the following:

 

·   The county of physical presence if the family’s residence is unclear, or

·   The county in which the family’s principal residence is located

 

Example:  An individual is involved in an automobile accident and hospitalized in County A.  The individual is expected to remain hospitalized for less than 30 days.  The individual has an intact family consisting of a spouse and two children living in County B. The County of Responsibility shall be County B.

 

For individuals in Long Term Care that have a public guardian/conservator or are incompetent, the County of Responsibility is determined in accordance with MPG 03.01.03, Items D and E.

MEM    PROC. 3C

 

B.
Persons without a Family

A.   For persons whose eligibility is not determined as part of a family, nor based on family income, the County of Responsibility is the county where the person lives and maintains residence.

 

Example: The Joneses have a home in County A.  Mr. and Mrs. Jones decide to end their marriage.  Mr. Jones lives in County B and Mrs. Jones and the children remain in the home in County A.  County A is responsible for Mrs. Jones and the children.  County B is responsible for Mr. Jones because Mr. and Mrs. Jones are no longer living together.  In this situation, there is no “marital tie” and Mr. Jones' income is not used to determine Mrs. Jones' or the children's share of cost.

 

When a person's residence or identification is unclear, the County of Responsibility is determined by the physical presence of the individual. The person shall be treated as a person without a family.

 

03.01.03 Out-of-Home Placement

 

A.
Public Agency/ Government Representative

A government representative is an employee of an administrative agency of a local, state, or federal government.  The employee may be a public guardian/conservator or social worker who has placement responsibility of the person.

 

If…

Then the County of Responsibility is where the…

a person is placed by a government agency/representative into a foster care home, board and care home, or a facility

placement agency is located if the public agency is the appointed guardian/ conservator of the person

the county where the foster care home, board and care home, or a treatment facility is located accepts a transfer of guardianship/ conservatorship

beneficiary is living.  The County of Responsibility remains with the placement county until the county agencies work out the transfer/ jurisdiction agreement

 

 

B.
Private Agency/State Employed Person

When a person is placed into a board and care home, group home, or treatment facility by a

·   guardian,

·   person employed by a private agency, or

·   the state to act as guardian/conservator for the person

 

The County of Responsibility shall be where the board and care home or treatment facility is located, unless a person’s eligibility is based on the family’s income or is determined as member of an MFBU which includes the family.

 

C.
Persons Placed in State Hospitals

Persons placed in state hospitals by a county mental health agency or a Regional Center for the developmentally disabled shall have their Medi-Cal eligibility determined by the county in which the state hospital is located, unless the person's eligibility is determined as part of a family or based on family income.  In this case, the County of Responsibility is determined in accordance with MPG 03.01.02, item A

 

D.
Placement in Long-Term Care after Release from a State Hospital
 

Persons released from a state hospital and placed in a long-term care facility will have their Medi-Cal eligibility determined by the county in which the long-term care facility is located, with the following exceptions:

 

If…

Then ...

the person(s) has a public guardian or conservator in the county that originally placed the person into the state hospital

that county remains the County of Responsibility, unless the county in which the long-term care facility is located agrees to accept guardianship or conservatorship of the person

The person’s eligibility is determined as part of a family or based upon family income

the County of Responsibility is determined in accordance with MPG 03.01.02, item A

 

 

E.
Long-Term Care – Incompetent/ Incapacitated Individuals

If the applicant/beneficiary's community spouse, family member or representative lives in another county within the State of California, staff is expected to work with the applicant/beneficiary or his/her representative to expedite the application/redetermination process.  Assistance for the applicant/beneficiary and/or his/her representative shall include but not limited to:

 

·   Reviewing the Statement of Facts

·   Gathering Information

·   Determining eligibility

·   Issuing benefits

 

Refer to Article 4, Section 2 for procedures dealing with Authorized Representatives and Representatives for incompetent individuals (key persons).

 

The county where the community spouse or applicant/beneficiary's representative resides shall be the County of Responsibility.  The responsible county is not determined by the county residence/location of the Authorized Representative appointed by a competent community spouse, responsible relative, or other knowledgeable representative.

 

If ...

Then ...

a non-institutionalized community spouse resides and maintains a home in County A and he/she applies in County A for the incompetent institutionalized spouse who is in an LTC facility in County B

County A shall:

 

·   accept the application

 

·   assist the community spouse in gathering information

 

·   determine eligibility for the institutionalized spouse

 

County A, where the non-institutionalized community spouse lives, shall retain the case for continued eligibility since the institutionalized spouse is unable to provide information

the individual is in a hospital in County A and is being released to an LTC facility in County A.  The individual is incompetent and unable to apply for Medi-Cal on his/her own.  The individual's adult child, who lives in County B applies for benefits in County B on behalf of the LTC parent

County B shall:

 

·   accept and process the application

 

·   assist the adult child in gathering information

 

·   determine eligibility for the individual in LTC

 

County B shall retain the case because the adult child is the beneficiary's representative acting on the beneficiary's behalf for continued eligibility in reporting changes

the individual is in a hospital in County A and is being released to an LTC facility in County A.  The individual is competent, but incapacitated. The individual's adult child, who lives in County B applies for benefits in County B on behalf of the LTC parent

County B shall:

 

·   accept the application

 

·   contact County A and forward the application/ information to County A

County A shall:

 

·   accept and process the application

 

·   assist the LTC applicant in gathering information

 

·   determine eligibility for the  individual in LTC

   

 

03.01.04 General Situations

 

A.
Public Assistance

For people eligible for Medi-Cal under CalWORKs or SSI/SSP, the County of Responsibility is established by the regulations of the specific public assistance program.

 

B.
Deceased Persons

The County of Responsibility for a deceased person is the county where the person was living at the time of death.

 

Example: A person was admitted to a hospital in County A to receive emergency medical treatment. The person died in the hospital. The person was living in County B at the time of death.  County B is the county responsible for taking the application; determining eligibility, and issuing benefits for the deceased person.

 

If the deceased person's family or representative applies in any county within the state, the county in which the applicant’s representative applies in shall accept the application and process the application under the courtesy application procedures.

 

C.
Persons Absent from the State

Persons who are absent from the state but retain California residence, in accordance with MPG Article 7, Section 5, have their Medi-Cal eligibility determined by the county which would have been the County of Responsibility prior to the person's absence from the state.

 

D.
Courtesy Application

A courtesy application is an application made in a county other than the County of Responsibility.  The county in which an applicant or his/her representative applies for benefits is the county responsible for making the initial eligibility determination even if it is not the applicant’s county of residence.  The county in which the individual or his/her representative applies must accept and process the application.  If all of the information required for making the eligibility determination is available, the county shall:

 

Step

Action

1

Review application for completion.

 

If …

Then …

complete

complete Step 2 and 3

incomplete

complete Step 4

  

2

Issue benefits promptly before the case information and verifications are transferred to the beneficiary’s residence county, the County of Responsibility.

3

Follow the procedures outlined in Article 3, Section 2 to process an Inter-county Transfer via an eICT.

4

Forward the application and all information collected within 15 days from the date of application to the County of Responsibility for follow-up and completion of the initial eligibility determination.

 

Example:  An individual lives in County A and becomes ill in County B.  The individual is immediately admitted to a hospital in County B.  County B has an outstationed eligibility worker at the hospital who receives a Medi-Cal referral from the hospital staff.  The individual, with the worker’s assistance, can complete the Application (SAWS1), Statement of Facts (MC 210), and provide County B with the sufficient information to determine initial eligibility.  County B shall grant the individual's benefits before transferring the continued eligibility case responsibility to County A, the beneficiary's county of residence.

 

E.
Persons Under 21 Years of Age

 When determining the County of Responsibility for a person under 21 years of age, parental control and the person's tax dependent status shall be evaluated.  Parental control for the purposes of determining the County of Responsibility is the authority of the parent(s) to make decision on the child's behalf, whether or not the control is actually exercised.  A child who is away at school but returns home on some weekends, holidays, or vacations and is subject to parental control is considered temporarily absent from the parents' household, regardless of the duration of the absence.

 

When ...

Then …

a person who is under age 21 is living away from home, and claimed by his/her parents as dependent for tax purposes

the County of Responsibility is where the claiming parents live (except for Minor Consent applications) if the parents live in the State

 a person is between age 18 and 21, living in California but his/her parents, who claim the child as a tax dependent, live out-of-state. 

the County of Responsibility is where the child lives but the parents must complete the MC 210, provide the county with information/verification, and cooperate with county staff in the child's eligibility determination process.  The county where the child is physically present shall contact the child's parents and ask the parents to complete the application and grant benefits to the child if eligibility conditions are met

The applicant is under age 21, living away from home and does not have information on his/her tax dependent status

the application for Medi-Cal shall be accepted in the county where the applicant lives