ARTICLE 5

                                                              SECTION 7

            

TRANSITIONAL MEDI-CAL (TMC)

 

1.        GENERAL

 

The purpose of this section is to provide instructions for processing Medi-Cal cases for persons granted Transitional Medi-Cal (TMC) and Four-Month Continuing Medi-Cal. Aliens receiving restricted benefits from a Section 1931(b)-Only case are also entitled to these programs. For instructions on processing Edwards vs. Kizer (Aid Code 38) one month Continuing Medi‑Cal, see MPG Article 4, Section 16.

 

 

 

 

 


ACWDL

03-45

2.        TMC FLYER

 

The TMC flyer, form MC 325 (Appendix A1-A2), is given to persons approved for CalWORKs and Section 1931(b)-Only and every six months thereafter. The flyer is called “Medi-Cal for Working People.” Included on the back of this flyer are questions that the CalWORKs and Section 1931(b)-Only recipients can answer if he/she has secured employment. The form may be returned to the county to determine TMC eligibility.

 

The TMC flyer must be included in all CalWORKs and Medi-Cal application packets. Workers are to include a TMC flyer and postage paid return envelope with the Notice of Action when a CalWORKs or Section 1931(b)-Only case is discontinued for failure to provide, including at annual redetermination. If the form is returned, the worker will determine if the recipient is entitled to TMC because of increased earnings. Workers are not to deny or discontinue benefits for failure to return this form. Workers must determine entitlement to TMC even if the form is returned several months after the discontinuance. The worker will grant TMC, if eligible, for the remainder of the TMC months, beginning with the month after Medi-Cal discontinuance.

 

 

 

 

 

 

 

 

 

 

MEM Proc.

5B-11

 


3.        INITIAL ELIGIBILITY DETERMINATION

 

A.       Determining Factors

 

Persons who are discontinued from Medi-Cal through their CalWORKs or Section 1931(b)-Only case may be eligible to an additional four, six, or twelve months of zero share-of-cost Medi-Cal, depending on the reason for the discontinuance. The CalWORKs or Section 1931(b) -Only worker handles the initial eligibility determination and granting action.

 

Workers are to identify those Section 1931(b)-Only cases that have a CalWORKs companion case. The worker is to immediately notify the companion case-carrying worker when there is a reported change that affects case eligibility, such as discontinuance due to increased earnings or an increase in child/spousal support payments. This is to ensure that all eligible persons are converted to the appropriate TMC/Continuing Medi-Cal Program, and their cases are forwarded to the TMC worker by the 15th of the first month of TMC/Continuing Medi-Cal.

 

 

 

 

B.       Period of Eligibility

 

The TMC or four-month period of eligibility begins with the first month of CalWORKs or Section 1931(b)-Only ineligibility.  This means if ineligibility actually occurred in the month of the CalWORKs or Section 1931(b)-Only discontinuance, or in a month prior to the CalWORKs or Section 1931(b)-Only discontinuance, the ineligible month(s) is counted as a month of "Continuing Medi‑Cal" eligibility. The family would only receive the remainder of the maximum of the 12 TMC months (i.e., maximum number of TMC months minus any final months of CalWORKs ineligibility). The CalWORKs or Section 1931(b) -Only worker makes the period of eligibility determination. The same rule applies if the family moves out of state then returns within the Initial or Additional TMC period.

 

 

 

 

 

 

 

 

 


MEM Proc.

5B-4

 

EXAMPLE:       CalWORKs or Section 1931(b)-Only discontinued April 30, but the family was ineligible for CalWORKs or Section 1931(b)-Only in April.  April would be the first month of TMC.

 

The Positive Action Code, 701 through 706, indicates the period of eligibility.  The third digit of the Positive Action Code identifies the number of months of eligibility.  The period of eligibility also appears on the granting NOA.

 

 

 

 

C.       Separate FBU/Computer Documents

 

Refer to Appendix B of this section for computer entry instructions.

 

Full-Scope benefits for TMC/Continuing Medi-Cal are issued on a separate FBU designated by numbers 70 through 79.

 

Restricted benefits for TMC/Continuing Medi-Cal are issued on a separate FBU designated by numbers 3A through 3E.

 

Computer documents and NOAs related to the TMC/Continuing Medi‑Cal will be filed in a separate financial folder marked "Continuing Medi‑Cal" which is always maintained in the CalWORKs or Section 1931(b)-Only case.

 

 

 

 

If the case already has a closed TMC/Continuing Medi‑Cal FBU of 70 through 79, or 3A through 3E, that document will be used.

 

FBUs in the 70 through 79 and 3A through 3E series are exclusive to Transitional and Four-Month Continuing Medi‑Cal.  These FBUs are not to be converted to any other aid type.

 

See Appendix C of this section for TMC aid codes.

 

D.       Case Transfer Policy

 

See flow chart in Appendix D1-D2 of this section.

 

 

 


1)      Non-Companion Cases

 

Discontinued CalWORKs or Section 1931(b)-Only cases, which are granted TMC or Four-Month Continuing Medi‑Cal, will be transferred to the designated TMC worker by the 15th of the first month of TMC/Continuing Medi‑Cal benefits.

 

2)      Companion CalWORKs and Section 1931(b)-Only Cases

 

Categorically Eligible (CE) Section 1931(b)-Only cases are maintained by the CalWORKs worker. The CalWORKs worker is responsible for assuring that the TMC case generated from the discontinued CalWORKs case and the active CE case is transferred to the TMC worker for processing. The following applies to all other companion cases:

 

·         Workers are to identify those Section 1931(b)-Only cases that have a CalWORKs companion case. The worker is to immediately notify the companion case-carrying worker, via a phone call and the Memo Screen on AES, when there is a reported change that affects case eligibility, such as discontinuance due to increased earnings or an increase in child/spousal support payments. This is to ensure that all eligible persons are converted to the appropriate TMC/Continuing Medi-Cal Program.

 

·         The CalWORKs worker always takes the lead in the conversion process.

 

·         The Section 1931(b)-Only worker does not take a discontinuance action until the CalWORKs TMC worker instructs him/her to do so.

 

·         The CalWORKs worker forwards the discontinued CalWORKs case with the TMC/Continuing Medi-Cal FBU to the CalWORKs TMC worker by the 15th of the first month of TMC/Continuing Medi-Cal benefits. A copy of the memo with the Section 1931(b)-Only companion case information is placed on top of the TMC/Continuing Medi-Cal FBU to alert the CalWORKs TMC worker of the existence of a companion case.

 

·         Upon receipt of the CalWORKs case, the CalWORKs TMC worker evaluates for Section 1931(b)-Only first. If it is determined that the TMC/Continuing Medi-Cal will continue, the TMC worker must:

 

o    send the beneficiary a 1931(b)-Only denial notice #941,

 

o    contact the Section 1931(b)-Only case worker and instruct the worker to discontinue those persons eligible for TMC or Four-Month Continuing Medi-Cal and to forward any needed information.

 

The TMC worker will add those persons entitled to full-scope benefits to the CalWORKs 70 FBU and open a 3A FBU for those entitled to restricted benefits.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


ACWDLs 01-17 & 01-33

 

 


·         If the CalWORKs TMC worker determines that there is eligibility to Section 1931(b)-Only, the CalWORKs TMC worker informs the Section 1931(b)-Only worker to add the CalWORKs persons to the Section 1931(b)-Only MFBU and forwards any needed information. The TMC worker discontinues the TMC/Continuing Medi-Cal FBU.

 

 

E.       Case Maintenance

 

1)      TMC WORKER

 

a)        The TMC worker receives the complete CalWORKs or Section 1931(b)-Only case, which includes the Continuing Medi‑Cal financial folder. Upon receipt, the TMC worker must evaluate all persons for Section 1931(b)-Only and approve if eligible. If Section 1931(b)-Only is approved, the TMC or Four-Month Continuing Medi-Cal is discontinued. If 1931(b)-Only is not approved, send the beneficiary NOA 941 to advise.

 

b)        The TMC worker ALWAYS checks for CalWORKs and Section 1931(b)-Only companion cases and takes the appropriate action to ensure that all persons entitled to TMC/Continuing Medi-Cal benefits are added to the appropriate TMC/Continuing Medi-Cal FBUs.

 

c)        While on TMC, if a family reports a decrease in income that puts them within Section 1931(b) limits, eligibility for Section 1931(b) must be evaluated and approved if eligible. If Section 1931(b) is approved, the TMC case is to be discontinued.

 

 

 

 

 

 

 

 


ACWDLs 01-17 & 01-33

 

 

 

 

 

 

 

 

 

2)      CalWORKs or Section 1931(b)-Only Worker

 

                        When some family members remain eligible to CalWORKs cash or Section 1931(b)-Only, only the Continuing Medi‑Cal financial folder is sent to the Medi-Cal TMC worker.  In this instance, the CalWORKs or Section 1931(b)-Only worker must file a piece of paper on the top of the right hand side of the Continuing Medi‑Cal financial folder with a notation that there is an active CalWORKs or Section 1931(b)-Only case for (name of family member[s]) and the CalWORKs or Section 1931(b)‑Only worker number.  The CalWORKs or Section 1931(b)-Only financial folder must be cross-referenced in the same manner.  When the TMC/Continuing Medi‑Cal FBU is closed, the financial folder must be returned to the CalWORKs or Section 1931(b)-Only worker for filing in the CalWORKs or Section 1931(b)-Only case.

 

 

 

 

4.        TRANSITIONAL MEDI-CAL (TMC)

 

CalWORKs or Section 1931(b)-Only based Medi‑Cal recipients, who are discontinued because of increased earnings or hours of employment and meet the specified reasons listed below, must be granted zero share-of-cost Transitional Medi‑Cal for a six-month mandatory series "Initial TMC." This will be followed by an optional additional six‑month period, "Additional TMC." There will be no break in aid.

 

 

 

 

 

ACWDL

03-45


A.       Eligibility Requirements

 

1)      The family must have received CalWORKs or Section 1931(b)-Only in at least three of the six months before the CalWORKs or Section 1931(b)-Only discontinuance.

 

2)      The family must continue to have a child living in the home and the family must reside in California. Persons age 18 or older are not eligible as children for CalWORKs, Section 1931(b) or TMC unless they are 18, enrolled in school and expected to graduate before their 19th birthday.

 

3)      CalWORKs or Section 1931(b)-Only ineligibility must result from the following:

 

 

 

 

 

 

a)        The return to work or increased earnings from employment received by the PWE parent or caretaker relative.

 

ACWDL

92-59

98-56

                                NOTE:      Return to work or increased earnings from employment of the stepparent do not qualify the family for TMC unless the stepparent is the caretaker relative.

 

New footer:- 10/96, Ltr 368                       

                        b)     When the family is discontinued from CalWORKs for failure to return a CW 7, is granted Edward vs. Kizer continuing Medi‑Cal (Aid Code 38), and the worker determines that the client could have been discontinued from CalWORKs for a TMC qualifying reason, TMC is granted effective the date of CalWORKs ineligibility.

 

 


4)      For TMC purposes, the definition of a caretaker relative is the person in the home responsible for the care and control of a dependent child.  The TMC caretaker relative must be one of the following:

 

a)        The father, mother, brother, sister, half brother, half sister, uncle, aunt, first cousin, nephew, niece, or any such person of a preceding generation denoted by the prefixes grand, great, great-great.

 

b)        The stepfather, stepmother, stepbrother, or stepsister.

 

c)        The spouse of any person specified in a) or b), even after the marriage has been terminated by death or dissolution.

 

d)        In a two-parent household, either parent can be classified as the caretaker relative and TMC eligibility may be due to the employment earnings of either parent.

 

The following two examples illustrate situations in which the family may or may not be eligible for TMC coverage:

 

Example 1:  A family received CalWORKs for 18 months. The parents were terminated because the time limit to receive aid expired, but the children continued on CalWORKs. The parents were determined eligible for Section 1931(b) (Aid Code 3N). In the next month, because PWE’s earnings increased, the family was terminated from cash and Section 1931(b). Because the children were eligible for CalWORKs and the parents for Section 1931(b) in three of the last six months, the family is entitled to TMC.

 


Example 2:  A family is receiving CalWORKs. The PWE just started working over 100 hours. The PWE would not be subject to the 100-hour rule. However, assume the increase in earnings makes the family ineligible for CalWORKs. The worker evaluates the family for Section 1931(b). Assume the family’s income does not exceed the Section 1931(b) limits. This family is eligible for Section 1931(b)-Only and does not need TMC.

 

ACWDL

95-85

B.       Determining the Causal Relationship (“Wholly or In Part”)

 

Loss of CalWORKs or Section 1931(b)-Only eligibility would be considered to be caused by an increase in earned income if the increase in earned income from employment was, by itself or in combination, sufficient to make the family ineligible.

 

 

 

MEM Proc.

5B-6

 


                        STEPS

 

                        a)     Determine if the increase in earnings from employment would have resulted in the loss of CalWORKs or Section 1931(b)-Only eligibility if all other factors in the case remained the same (i.e., as if there were no other change in income, no change in family composition, no change in income standards, etc.)

 

If YES, the family is eligible to receive TMC.

 

If NO, go to step b).

 

                        b)     Determine if events other than the increase in hours or earnings from employment would have resulted in loss of CalWORKs or Section 1931(b)-Only eligibility if the income hours or disregards had stayed the same.

 

If YES, the family is not eligible for TMC.  Do not go to step c).

 

If NO, go to step c).

 

                        c)     Determine if the family is ineligible for CalWORKs or Section 1931(b)-Only when all changes are considered.

 

If YES, the family is eligible for extended Medi-Cal benefits.  The increase in earnings from employment was essential to the loss of CalWORKs or Section 1931(b)-Only eligibility. Without that increase, the family would not have lost CalWORKs or Section 1931(b)-Only eligibility.

 

If NO, the family is still eligible for CalWORKs or Section 1931(b)-Only.

 

EXAMPLE 1:  The caretaker relative, in a family with no other income, becomes employed on June 1 and reports countable earned income of $400 in June.  At the same time, the caretaker relative reports that beginning with June the family is receiving monthly unearned income of $800.  Assume the CalWORKs standard is $775 and the family is no longer eligible for CalWORKs or Section 1931(b)-Only in June due to excess income, which is both earned and unearned.

 

Step a) Would the increase in income result in termination if all other factors remained the same? The answer is "no."  The earned income of $400 alone did not result in the loss of CalWORKs or Section 1931(b)-Only.  That is, if all other factors in the case remained the same, the $400 would not have caused ineligibility.  Continue to step b.

 

Step b) Did other events cause the termination? The answer is "yes."  The unearned income alone would have resulted in the loss of CalWORKs or Section 1931(b)-Only.  The $800 increase in unearned income alone was sufficient to make the family ineligible for CalWORKs or Section 1931(b)-Only even if all other factors stayed the same. Therefore, the family is not eligible for TMC.  Do not continue to step c.

 

 

EXAMPLE 2:  The principal wage earner (PWE), in a family with no other income, becomes employed on June 1 and reports countable earned income of $700.  In July, one child leaves the household.  As a result, the income standard for the family in July is reduced to $624. The family is no longer eligible for Section 1931(b) in July due to excess income, all of which is earned.  However, the family is not eligible for TMC because the earnings of the PWE did not increase in July, the month in which Section 1931(b) eligibility was lost.

 

 

EXAMPLE 3:  A caretaker relative is employed and has monthly countable earned income of $375.  The caretaker relative reports that she no longer has to pay for day care in June because free care is available.  Without child care expenses, her countable earned income increased to $750 in June.

 

The family is no longer eligible for Section 1931(b) in June because of excess income.  However, the family is not eligible for TMC because the earnings of the caretaker relative did not increase in June, the month in which Section 1931(b) eligibility is lost.

 

EXAMPLE 4:  A mother and her child are recipients of Section 1931(b) on the basis of absence of the father. The father returns home. The family must now be evaluated for Unemployed Parent Deprivation. The father is determined to be the PWE. He is working over 100 hours and the parents’ earned income is over the Unemployed Parent Deprivation limit. The family’s income is also over the Section 1931(b) limit. This family is not eligible for TMC because the family was discontinued from Section 1931(b) due to loss of deprivation rather than increased hours or earnings from the mother’s employment. She was the caretaker/principal wage earner in the home.

MEM Proc.

5B-4



C.       Period of Eligibility

 

See Appendix B of this section for computer entry instructions.

 

1)       Initial TMC  (Also see 3.B. above)

 

       Aid Code 39-0 is to be used for full-scope benefits.

       Aid Code 3T-0 is to be used for restricted benefits.

 

 

 

 


a)        Eligibility will continue for the six months immediately following the last month of CalWORKs or Section 1931(b)-Only eligibility.  There will be no break in aid. (Positive action codes 701-706).

 

b)        There are only three reasons Initial TMC can be terminated prior to the end of the six months:

 

(1)        There is no longer a child (as defined in 4. A. 2) in the MFBU.  In this case, eligibility ends the last day of the month in which the last child is in the home so long as adequate notice is given.

 

(2)        The persons in the TMC MFBU are evaluated and determined eligible for Section 1931(b).

 


(3)        New footer:- 2/96, Ltr 343.  New page 4.Loss of California residency.

 

c)        If the client fails to return a completed Status Report in the fourth month of Initial TMC without good cause, TMC eligibility will end the last day of the sixth month of TMC.  If the completed Status Report is returned prior to the discontinuance date, aid will be reinstated.

 

d)        Any family that becomes ineligible during Initial TMC is NOT eligible to Additional TMC.

 

EXAMPLE A:  The only child left the home in the third month of the Initial TMC period. The family was terminated from TMC. In the fifth month, the child returned. The family is eligible to receive the remaining two months of the Initial TMC period; however, they are not eligible for additional TMC because they did not receive the entire six months of TMC.

 

EXAMPLE B:  The family moved to another state in the first month of the Initial TMC period. Although the family continues to meet all the TMC requirements, benefits must be discontinued because they are no longer in California. The family returned to California in the third month of the Initial TMC period. They may receive the remainder of the Initial six-month period and the six months of Additional TMC if they are otherwise eligible since the family continued to be eligible for TMC even though they did not actually receive TMC when they were living out of state. This is an exception to the rule that the family must have actually received the entire Initial period of TMC.

 

 

 


2)       Additional TMC

 

        Aid Code 59-O is to be used for full-scope benefits.

        Aid Code 5T-0 is to be used for restricted benefits.

 

a)        Eligibility will continue for the six months immediately following termination of Initial TMC (Positive Action Codes 701-706) unless one of the following situations occur:

 

 

 

 


(1)        The MFBU no longer includes a child. (As defined in 4. A. 2).

 

(2)        The persons in the TMC MFBU are evaluated and determined eligible for Section 1931(b).

 

(3)        The MFBU fails to meet the reporting requirements; including the Status Report and no good cause exists.

 

(4)        Neither parent nor caretaker relative is employed and “good cause” (outside the control of the employed person) was not determined.

 

 

 

 

 

 

 

MEM Proc.

5B-5


                    

(5)        The family gross earnings minus "out-of-pocket" expenses for childcare exceed 185% of the federal poverty level for the quarterly report period.  (See Article 10, Section 7 for TMC income computation information.)

 

(6)        The family became ineligible during Initial TMC.

 

 

 

 

 

 

 

(7)        The family declines the choice to receive Additional TMC.

 

(8)        Loss of California residency.

 

b)        A ten-day NOA is required for termination of TMC.

 

 


3)       Second Year TMC 

 

The State-funded, Second Year TMC Program was discontinued effective October 1, 2003. The aid codes used for Second Year TMC were:

 

                        Aid Code 5X-O used for full-scope benefits.

                        Aid Code 5Y-O used for restricted benefits.

 

 

 

ACWDL

03-45

 

 

 

 

4)       Continuing Eligibility

 

a)        If it appears a family member is eligible, Medi‑Cal eligibility must be evaluated under another program before TMC eligibility can be terminated.  Send an MC 210, MC 219, and all other Medi-Cal forms as necessary for a new applicant and provide the applicant with a specific time limit to provide the information.  A statement of citizenship/national/alien status should already be in the file and should not have to be requested again.  If a statement of citizenship/national/alien status cannot be located in the case for non-citizens or an adult who did not sign the MC 210, send an MC 13.

 

 

ACWDL

90-66

 


ACWDL 03-14


 

b)        There is no Edwards vs Kizer process (Aid Code 38) for persons receiving restricted benefits from any TMC FBU. In these situations, the TMC FBU is to be extended for an additional month if a timely redetermination has not been made by the end of the TMC period and the worker was unable to provide timely and adequate notice to discontinue benefits.

 

c)        An Edward vs Kizer (Aid Code 38) is generated for those persons receiving full-scope benefits from an Initial or Additional TMC FBU and whose period of TMC eligibility ends before the worker is able to complete a Medi-Cal redetermination.

 

d)        If an Edwards vs Kizer case is generated and eligibility cannot be determined, discontinue the case at the end of the month for failure to provide information.

 

e)        Once TMC is terminated and there is a break in aid, TMC cannot be reinstated.

ACWDL

03-45

 

 

 

 

 


D.       Determining The TMC Family Members

 

1)      Eligible Family Members

 

In addition to the individuals who were included in the CalWORKs or Section 1931(b) family unit at the time the family lost eligibility, family members who enter the home during the initial, additional six-month period, or the second year (if 19 or older), may be eligible for TMC. These include:

 

a)        Newborn or adopted children.

 

b)        Family members under CalWORKs sanction for failure to cooperate with GAIN or child/spousal support whose income, but not needs, were included in the CalWORKs unit.

 

c)        Family members deemed to be receiving CalWORKs because they are participating in work supplementation programs.

 

d)        Family members who would have been eligible for CalWORKs or Section 1931(b)-Only if they had been in the home in the month the family was determined to be ineligible.

 

e)        Family members who were terminated from SSI due to increased earnings from other family members on CalWORKs or Section 1931(b).

 

The earned income of an individual who has entered or returned to the home must be included in the gross family income assessment if he/she wishes to receive TMC.  Individuals added to the TMC case only receive TMC for the remainder of the family's TMC period.

 

 

 

 

 

 

 

 

 

 

 

MEM Proc.

5B-5

 

 

 

 

 

 

 

 

 

Note:  An absent parent or spouse who returns home with earnings from employment, which causes the family to lose CalWORKs or Section 1931(b), does not qualify the family for TMC.

MEM Proc.

5B-6

 

2)      Ineligible Family Members

 

The following people are not eligible for TMC:

 

a)        Returning family members who would not have been eligible to CalWORKs or Section 1931(b)-Only in the month of discontinuance.

 

b)        Family members who were not eligible or would not have been eligible and whose income and resources were not counted for CalWORKs or Section 1931(b)-Only, e.g. persons receiving SSI, children over the age limit, parents or mutual children with no linkage, the father of an unborn, or a non-needy caretaker relative. These individuals are described as "excluded persons" in the CalWORKs or Section 1931(b)-Only Program. Some of those who are excluded from CalWORKs, i.e., a person who does not meet alien status requirements or a sanctioned person, may be aided under Section 1931(b) if they meet the TMC requirements.

 

 

c)        Family membersNew footer: 10/96, Ltr 368, a page; new page 5 terminated from CalWORKs or Section 1931(b)-Only due to the change in the treatment of State Disability Insurance (SDI) payments from unearned to earned income are not eligible for TMC since this is not considered actual earnings from employment.

 

d)        Family members who remain eligible for Section 1931(b) because they are a Sneede class member and they are in a separate MBU.

 

e)        Family members who were convicted of fraud during the last six months in which the family was receiving CalWORKs or Section 1931(b)-Only.

 

f)         Family members who are not parents or caretaker relatives and who do not meet the CalWORKs definition of a child (over 18 and not enrolled in school and expected to graduate by age 19) unless they are a child prior to entering TMC. Then they may remain eligible unless they are the youngest child in the home. In that case, the entire TMC family must be terminated.

 

 

 

g)        Family members who were terminated from CalWORKs or Section 1931(b) due to the loss of deprivation when a parent or spouse with earnings from employment returns home or is added to the family.

MEM Proc.

5B-6


 


E.       Persons Leaving the Home

 

TMC will continue for families if the parent/spouse or children leave the home in either the initial or additional TMC period; however, the remaining TMC family must continue to reside in the State and include a child. The family size will be reduced when comparing average earned income during the additional six-month period since the person(s) who left will no longer be included in the MFBU. The family’s earned income may also be reduced to the extent the person who left had earned income. If the family size has changed during the preceding three-month period, use the current family size.

 

F.       MFBU Composition

 

When determining Medi-Cal eligibility for other family members, TMC recipients are considered ineligible members of the MFBU belonging to those persons who are not eligible for TMC. The Medi-Cal health care costs incurred by TMC recipients may be used to reduce other family members’ or responsible relatives’ share of cost. They are coded M in the PC code box.

 

It is possible that some persons will be eligible for Section 1931(b) and some will be eligible for TMC because deprivation still exists. For example, assume unmarried parents with mutual and separate children are eligible for Section 1931(b) based on the father’s incapacity. The father recovers, returns to work, must be evaluated for U-Parent deprivation, and is determined to be the Principal Wage Earner. Since he is working over 100 hours and there has been a change in circumstances, the earned income U-Parent test is required. The family fails this test. Dad and the mutual children are eligible for TMC due to increased hours of employment, but the mother and her separate children are still income eligible for Section 1931(b) as recipients based on absence of the separate children’s father. It is also possible that the family is eligible for TMC, but their 20 year old “child” is not because he/she does not meet the definition of a child for Section 1931(b) or the first year of TMC. He is aided as MI.

 

Due to Sneede rules, some persons may continue to be eligible for Section 1931(b) even if some of the other family members are over the income or resource limits and eligible for TMC. Section 1931(b) persons may continue to receive Medi-Cal until they are no longer eligible. If they have received Medi-Cal under the Section 1931(b) program for three of the last six months, and have been terminated for increased earnings from employment, they are then entitled to TMC for the entire TMC period if they remain eligible. This is true even if other members of the family have already been receiving TMC in prior months. They will have status reporting due dates different from the other members of the family who began TMC in earlier months.

 

 

 

 

 

 

 

 

 

 

 

 

 

MEM Proc.

5B-10

When calculating family size to compare to 185% of FPL for the additional 6-months of TMC, use the entire family size regardless of whether they are receiving TMC.

 

MEM Proc.

5B-12


G.      Return to CalWORKs or Section 1931(b)

 

If a family returns to CalWORKs or Section 1931(b) during any of the TMC periods and is then terminated due to another reason which does not meet the requirements of TMC, e.g., is not related to employment or does not meet the three out of the preceding six-month requirement, the family is eligible for the remainder of the original TMC period if they are otherwise eligible. The months of zero share-of-cost Medi-Cal which the family received when they returned to CalWORKs or Section 1931(b) are counted as if TMC were received in those months, i.e., they are counted as part of Initial or Additional TMC or the second year of TMC for purposes of determining the remaining months original TMC period. If they met the requirements of TMC when terminated, they are evaluated for a new initial TMC period.

 

For example:  The family was terminated from CalWORKs due to increased hours or earnings from employment of the caretaker relative. They received TMC for four months. The caretaker became unemployed and the family was again eligible for CalWORKs. After two months, the caretaker found another job and was terminated from CalWORKs. NOTE: The two months of CalWORKs cash-based Medi-Cal counted as if TMC were received and completes the initial TMC period. The family is not eligible for initial TMC under a new TMC program because they did not receive CalWORKs for three out of the preceding six-month requirement; however, they are eligible to receive an additional six months of the original TMC period if all other eligibility criteria are met. NOTE: Persons who were terminated from CalWORKs or Section 1931(b) must meet deprivation rules, e.g., working under 100 hours, when they lose TMC and return to those programs.

 

 


H.       Beneficiary Reporting Responsibilities

 

1)      Beneficiaries are responsible to report any changes in income, assets or living situation to the worker within 10 days.

 

 

 

 

 

2)      Quarterly Status Reports (QSR) are required during First Year TMC. 

ACWDL

03-45

I.         Status Reports MC 176 TMC

 

See flow charts in Appendix E1-E7.

 

1)      Due Dates

 

a)        Initial TMC-families must provide a Status Report no later than the 21st day of the fourth month of TMC.  If the 21st of the month falls on a Saturday, Sunday or holiday, the report will be due on the first work day following the 21st.  This report will be used to determine eligibility for the six month Additional TMC period.

 

 

 

 

 

 

b)        Additional TMC-families must provide Status Reports by the 21st day of the first and fourth months of Additional TMC.  If the 21st of the month falls on a Saturday, Sunday or holiday, the report will be due on the first workday following the 21st.  This report will be used to determine all eligibility factors and if the family's gross earned income exceeds 185% of FPL.

 

c)        Status Reports will be automatically issued to the beneficiary in the month before they are due. (Refer to Appendix B of this section for current instructions as not all QSRs are issued automatically at this time.)

 

 

 

2)      Consequences of Late or Incomplete Status Reports

 

a)        Initial TMC

 

(1)       If the Status Report is not returned complete during the initial six-month period, TMC is not discontinued until the end of the six-month period.  Benefits for the additional six-month period will be denied.

 

(2)       The worker must attempt to call the beneficiary, if a phone number is provided, to encourage him/her to return the Status Report and offer assistance as needed. The attempted contact must be narrated.

 

(3)       If the TMC Status Report is fully completed and returned later than the 21st day of the fourth month, but prior to the actual discontinuance date, the family may be eligible for the additional six-month period.

 

(4)       Discontinuance NOA 079 will be used for incomplete and non returned Status Reports.

 

 

 

 

 

 

b)        Additional TMC

 

(1)       If a completed Status Report is not returned by the due date, aid will be discontinued with adequate notice.

 

(2)       The worker must attempt to call the beneficiary, if a phone number is provided, to encourage him/her to return the Status Report and offer assistance as needed. The attempted contact must be narrated.

 

(3)       If the completed Status Report is received within 30 days of the date it was due, TMC will be reinstated, if eligible.

 

 

 

c)        NEW FOOTER - : 6/90; Letter #: 111At present, there is no mandated SDHS requirement or process to return incomplete Status Reports to the client.  Workers will photocopy the incomplete Status Report and return it to the client with the discontinuance NOA.  The incomplete areas of the Status Report should be circled in red.

 

 


 

3)      Good Cause

 

Good Cause for not meeting the quarterly reporting requirements during first year TMC exists only when the beneficiary cannot be reasonably expected to fulfill the reporting responsibility due to factors outside his/her control.  The burden of proof rests on the beneficiary.

 

 

 

 


a)        A Good Cause exemption shall only be granted if the parent, other caretaker relative or an authorized representative makes the request.

 

 

 

(1)       A request is defined as any clear expression to the County, whether verbal or written, that the beneficiary wants an opportunity to present his/her explanation for not meeting the monthly reporting requirements.

 


 

(2)       In lieu of a request, as required in a) above, the County has the discretion to independently determine that one of the following reasons for Good Cause exists:

 

·         The beneficiary is suffering from a mental or physical condition that prevents timely and complete reporting.

 

·         The beneficiary's failure to submit a timely and complete report is directly attributable to a County error.

 

·         Other extenuating circumstances are found.

 

b)        When the beneficiary has Good Cause for not reporting timely, rescind the discontinuance.

 

 

 

 

4)      Complete Status Report

 

                        A complete Status Report must meet all of the following criteria:

 

a)        All questions must be answered "yes" or "no" or an indication of a "yes" or "no" answer made by written entries under that item and/or by verifications enclosed with the report.

 

b)        The report must include the following information for each of the preceding months:

 

(1)       MFBU composition.

 

 

 

 

(2)       Gross monthly earnings and who received the income.

 

(3)       Out-of-pocket child care expenses necessary for the employment of the caretaker relative.

 

 

 

 

c)        Verification of any change in income, or other health coverage must be included in the report, unless previously verified.

 

d)        The Status Report must be signed and dated by the beneficiary.  If the date signed and/or the date the report is received by HHSA is prior to the first of the month in which it is due, the Status Report will be accepted.

 

 

5)      Status Report Budgeting for Family Income

 

                        See Article 10, Section 7.

 

 

NEW FOOTER - : 10/96; Letter #: 368


J.        Mandatory Informational Notices

 

These will be sent automatically. (Refer to Appendix B for current instructions.)

 

                1)     Initial TMC-Notices Are Sent:

 

a)        In the third month, outlining the information needed to complete the Status Report.

 

b)        In the sixth month outlining

 

(1)       Information needed to complete the Status Report in the first and fourth months of the Additional TMC period.

 

(2)       A description of "out-of-pocket" expenses.

 

(3)       A description of the benefits provided by Additional TMC.

 

(4)       Reporting requirements of Additional TMC.

 

 

 

 

 


2)      Additional TMC-Notices Are Sent:

 

a)        In the third month that outlines the information needed to complete the status report.

 

b)        When termination is due to excess income, failure to report or lack of earnings, the NOA must explain how families can reestablish eligibility to another program, per C.4 above.

 

c)        In the twelfth month, a NOA must be sent to explain continuing Medi‑Cal eligibility, per C.4 above.

 

 

 

 

 

 

ACWDL

90-66

K.       Transitional NOAs

 

1)      For termination from TMC, the normal ten-day notice is required.

 

2)      For terminations due to excess income, failure to report or lack of earnings during the additional TMC period, NOAs will explain how families can reestablish eligibility for another Medi‑Cal program, per C.4 above.

 

 

 

 

ACWDL

90-66

 

L.        Discontinuance for Failure to Provide

 

If a TMC beneficiary has been sent a request for information and has failed to provide the necessary information, the case will be set to close for failure to provide. The worker must attempt to call the beneficiary when initiating the discontinuance and encourage him/her to return the needed items and offer assistance as needed. The attempted contact must be narrated in the case file. If the beneficiary has good cause and needs additional time, the worker is to establish a reasonable extended deadline.

 

M.      Worker Alerts

 

Worker alerts will be automatically generated for Initial TMC and Additional TMC two months prior to the termination date.  These will alert the worker that the end of the TMC period is approaching.

 

 

 

 


N.       Inter County Transfers (ICTs)

 

Persons receiving TMC who move to another county are treated the same as any other family receiving Medi-Cal.  However, the initiating county maintains the responsibility for monitoring, when appropriate, and discontinuing the case.

 

 

MEM 50137

MEM Proc.

5B


 

5.        FOUR-MONTH CONTINUING MEDI-CAL

 

Provides zero SOC Medi-Cal. Benefits begin in the month in which the family became ineligible to CalWORKs or should have been considered ineligible.

 

         Aid Code 54-X is used for full-scope benefits.

         Aid Code 5W-X is used for restricted benefits.

 

A.       Four-Month Continuing Medi‑Cal is granted when:

 

1)      CalWORKs or Section 1931(b)-Only is discontinued solely, or in part, due to collection or receipt of increased child/spousal support;

 

2)      The family is not eligible to Section 1931(b)-Only;

 

3)      The child or spouse, for whom the support payment is intended, received CalWORKs or Section 1931(b)-Only, or a zero basis grant solely due to an overpayment adjustment, and was eligible to the grant, in at least three of the six months prior to the month ineligibility occurred; and

 

4)      The person(s) must reside in California. Should the person(s) leave California but then return to California prior to the expiration of the four months, he/she may receive the remainder of the four months. Persons who were terminated from a cash program similar to CalWORKs or Section 1931(b)-Only in another state are not entitled to Four-Month Continuing benefits in California.

 

 

 

MEM Proc.

5B-1

B.       Determining the Causal Relationship (“Wholly or In Part”)

 

There must be a causal relationship between the support increase and the ineligibility for CalWORKs or Section 1931(b)-Only.  For example, the family may be terminated from CalWORKs or Section 1931(b)-Only due to a change in family circumstance at the same time that support increased.  If this increase would not by itself be the cause of the CalWORKs or Section 1931(b)-Only termination, the family would not be eligible for Four-Month Continuing benefits.  However, Four-Month Continuing is allowed if the increase or collection of support is not enough to terminate the family from CalWORKs or Section 1931(b)-Only, but would if combined with another circumstance, e.g. an increase in unearned income.

 

Example 1:  A Section 1931(b) family of four receives $300 in countable child support for two of three children.  The third child turns 19 and moves out of the household.  Assume that because the income exceeds the standard for assistance for a family of three, the family is ineligible for Section 1931(b).  Four-Month Continuing benefits are not granted because there was no increase in support collection; ineligibility was caused by the adjustment in the standard of assistance.

 

Example 2:  A CalWORKs family receives $325 in countable child support.  The applicable standard of assistance is $775 for a family of that size.  In the next month, the countable support increases to $650 and at the same time, one of the older children leaves home.  The standard of assistance is reduced to $624 due to the reduction of family size and the family becomes ineligible for CalWORKs and Section 1931(b). Four- Month Continuing benefits were granted because although the increase in support collection was not sufficient in itself (wholly) to cause ineligibility when combined (in part) with the reduction in the standard of assistance, the family lost eligibility.  Furthermore, since the reduction in the standard of assistance, when compared to the original amount of child support of $325, was insufficient by itself to cause ineligibility, the ineligibility was not caused "partly" by the support collected.  Thus, the change in child support did not cause or actively contribute to the loss in eligibility.

 

MEM Proc.

5B-1

NEW FOOTER - : 10/96; Letter #: 368.  ^Ba page, new page 9.Example 3: A Section 1931(b) family receives $300 in countable child support and $200 in Title II benefits.  The applicable standard of assistance is $624 for a family of that size. In the next month, both the child support and Title II increase by $150 each.  The family's income (now at $650) makes them ineligible due to excess income.  Because the increase in Title II benefits and child support were both necessary to cause ineligibility, and the child support actively contributes to ineligibility, the family is eligible for Four- Month Continuing benefits.

 

 

C.       MFBU Composition

 

All family members required to be in the CalWORKs or Section 1931(b)-Only FBU in the first month of ineligibility, which resulted in Continuing Medi‑Cal, are included in the Continuing Medi‑Cal FBU. The CalWORKs or Section 1931(b) -Only worker makes the MFBU composition determination.

       

Persons receiving Four-Month Continuing Medi-Cal shall be ineligible members of the MFBU when determining Medi-Cal eligibility for other family members and may use their non-covered Medi-Cal health care costs to reduce the other family member’s share of cost. Exception: In accordance with the Sneede v Kizer lawsuit settlement, only responsible relatives may use their expenses to reduce family member’s share of cost in other mini-budget units (MBUs).

 

 

 

MEM Proc.

5B-2

 


D.       Eligibility Factors

 

Persons eligible to Medi‑Cal under this aid code remain eligible, regardless of whether other eligibility factors are met, unless the person dies, becomes eligible to cash-based Medi‑Cal, moves out of California, or requests discontinuance.  For example, this means that persons eligible under this category, who acquire property that would make them ineligible under any other aid category, are still entitled to zero share-of-cost Medi‑Cal through the end of the four-month eligibility period.  Should a person leave California, but then return prior to the expiration of the four months, he/she may receive the remainder.

 

 

 

 

 

 

 

MEM Proc.

5B

 

E.       Request for Restoration

 

Persons discontinued from Four-Month Continuing Medi‑Cal under Aid Codes 54 and 5W, who request restoration of Medi‑Cal within the original four-month period of Continuing Medi‑Cal eligibility, are to be restored Medi‑Cal under the 54 or 5W aid code for the balance of the remaining eligibility period. The worker will restore Medi‑Cal beginning with the month of the restoration request.  A new eligibility determination is not required.  When such a situation is discovered at intake, and the four-month period extends beyond the current month (month of granting action), the worker should request the closed CalWORKs or Section 1931(b)-Only case and reopen the Continuing Medi‑Cal FBU.

 

F.       Redetermination Process at End of Four Months

 

The provisions of the Edwards vs. Kizer (formerly known as Edwards vs. Myers) court order apply to persons receiving full scope (Aid Code 54) Four-Month Continuing Medi-Cal whose period of eligibility ends. Edwards vs. Kizer does NOT apply to persons terminated from Aid Code 5W (restricted benefits). Refer to MPG Article 4, Section 16, for instructions for processing the redetermination.

 

                Every effort should be made to complete the redetermination in time to notify the beneficiary of eligibility or ineligibility to Medi‑Cal Only.  However, if this is not possible by NOA 10-day deadline, the worker must convert the 54 full-scope FBU to an Edwards Aid Code 38 case. Positive Action Code 410 and Negative Action Code 079 are to be used.  NOA 916 must also be sent.  The 5W restricted benefits FBU is to be extended for an additional month if a redetermination has not been made and the worker was unable to provide timely and adequate notice to discontinue the benefits at the end of the four-month period.

 

                If it is necessary to convert a Four-Month Continuing 54 full-scope FBU to Edwards Aid Code 38, completion of the eligibility determination for Medi‑Cal Only becomes an intake function at the point Form MC 210 is returned.

 

 

 


G.       Inter-County Transfers (ICTs)

 

When a family receiving Four-Month Continuing Medi-Cal moves from the first county to the second county, an ICT must be initiated by the first county to the second county. The first county is responsible for case activities and benefit issuance until the last day of the final month in which eligibility exists for the family under the Four-Month Continuing Medi-Cal coverage.

 

 

 

MEM Proc.

5B-2

 

 





APPENDIX B

 

 

AUTOMATION AND CDS ENTRY INSTRUCTIONS FOR TRANSITIONAL (TMC) AND

FOUR-MONTH CONTINUING MEDI-CAL

 

 

Staff were notified via export notes that the following automated enhancements were implemented effective October 2000:

 

·         The series of 700 Positive action codes (707-712) allowing CDS and MEDS to discontinue timely.

 


·         The range of close codes entered in the close code box was expanded to include (G-L).

 

·         Automating the Quarterly Status Reports to generate off of the new aid types of 3T-0 and 5T-0.

 

The ETs must set up cases manually for restricted TMC benefits.

 

There are separate aid types and NOAs for restricted TMC and 2nd Year TMC. They are case level and will be entered on the APPL or ELIG screen depending on the point of creation. 

 

TMC/CONTINUING MEDI-CAL AID TYPES AND FBUs

 

The following is a list of all aid types and FBUs:

 

54-X – Four-month continuing (full-scope)                       FBU series 70-79

54-X – Four-month continuing (full-scope)           FBU series 3H-3Q (from closed 1931b Medi-Cal only)

5W-X – Four-month continuing (restricted)                      FBU series 3A-3E

 

39-0 – Initial six months TMC (full-scope)                        FBU series 70-79

39-0 – Initial six months TMC (full-scope)            FBU series 3H-3Q (from closed 1931b Medi-Cal only)

3T-0 – Initial six months TMC (restricted)             FBU series 3A-3E

 

59-0 – Additional six months of TMC (full-scope)                        FBU series 70-79

59-0 – Additional six months of TMC (full-scope)            FBU series 3H-3Q (from closed 1931b Medi-Cal only)

5T-0 – Additional six months TMC (restricted)                 FBU series 3A-3E

 


WORKER ENTRIES

 

The following outlines several case situations and how to set up the TMC case:

 

SITUATION 1

 

Section 1931(b) case (AA FBU) active with one full-scope parent and one minor U.S. child; one restricted benefits parent and one restricted benefits child; no companion CalWORKs case. Section 1931(b)-Only case closes for increased earnings.

 

ACTION: ETs must transfer the Section 1931(b) case (AA FBU) to the 3H FBU for the full-scope beneficiaries and 3A FBU for the restricted beneficiaries with the following entries on BDLM:


Full-scope benefits: Copy AA FBU to 3H FBU and change aid type to 39-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes in the series of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligibility;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 


Restricted benefits: Copy AA FBU to 3A FBU and change aid type to 3T-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligibility;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 

SITUATION 2

 

CalWORKs active with two minor U.S. children; two parents excluded due to sanctions and active on a categorically eligible (CE) Section 1931(b) case receiving full-scope benefits.  CalWORKs case closes for increased earnings.

 

ACTION:  ETs will transfer the CE case to the 70 FBU with the following entries on BDLM:

 

Full-scope parents: Close the CE case and add parents to the TMC case with the 70 FBU with the full scope children;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 

SITUATION 3

 

CalWORKs active with two minor U.S. children; one parent is sanctioned and active on a CE case receiving full-scope benefits and the other parent is undocumented and active on the same 1931(b) case receiving restricted benefits.  CalWORKs case closes for increased earnings.

 

ACTION:  ETs must transfer the full-scope beneficiary from the CE FBU to the 70 FBU opened when the CalWORKs case closed and transfer the restricted beneficiary to the restricted TMC aid type and FBU with the following entries on BDLM:

 


Restricted benefits: Copy the CE FBU to 3A FBU and change aid type to 3T-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligibility;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

Full-scope benefits: Close the CE FBU and add the beneficiary to the TMC case on the 70 FBU with the full-scope children;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen for parent.

 

SITUATION 4

 

CalWORKs case (one parent and two U.S. citizen children) closes for increased earnings and all eligible members of the household convert to a TMC case with a 39-0 aid type and a 70 FBU.  Restricted family member (one Non-U.S. child) is active on a Section 1931(b)-Only case.

 

ACTION: ETs must close Section 1931(b)-Only case and transfer restricted TMC family member to the new aid type and FBU series with the following entries on BDLM:

 


Full-scope benefits: Use appropriate closing code on CalWORKs to generate TMC case or set up TMC case manually.

 


Restricted benefits: Copy CE FBU to 3A FBU and change aid type to 3T-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligibility;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 

SITUATION 5

 

Section 1931(b) case (AA FBU) active with one full-scope parent and one minor U.S. child; one restricted benefits pregnant parent (eligible to Income Disregard Program) and one restricted benefits child; no companion CalWORKs case.  Section 1931(b) case closes for increased earnings.

 


ACTION:  ETs must transfer the Section 1931(b) case (AA FBU) to the 3H FBU for the full-scope benefits and 3A FBU for the restricted benefits and set up a FPL case with a 55 FBU for pregnancy related benefits with the following entries on BDLM:

 


Full-scope benefits: Copy AA FBU to 3H FBU and change aid type to 39-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligible;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 


Restricted benefits: Copy AA FBU to 3A FBU and change aid type to 3T-0 beginning the first of the following month;

 

Delete Application code and date from ELIG screen after copy feature is completed;

 

Use codes of 7** on positive code on the ELIG screen corresponding to the correct amount of months of TMC eligible;

 

Use 7** positive codes on PDT1 corresponding to the codes used on the ELIG screen.

 

Open a second FBU (55) for the FPL pregnancy related benefits with aid type 48 in the usual manner.

 


APPENDIX C

 

SECTION 1931(b)-ONLY AID CODES FOR TMC AND FOUR-MONTH

CONTINUING MEDI-CAL CONVERSIONS

 

 

 

 

TMC

 

 

CDS

FIELDS

1931(b) AID TYPE

INITIAL TMC

1ST 6 MO.

ADD. TMC

2ND 6 MO.

 

US CHILD

 

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3N0

AA FBU

 FULL-SCOPE

39-0

 

3H FBU

FULL-SCOPE

59-0

 

3H FBU

FULL-SCOPE

NOT QUALIFIED ALIEN ADULT

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3V0

AA FBU

RESTRICTED

3T-0

 

3A FBU

RESTRICTED

5T-0

 

3A FBU

RESTRICTED

NOT QUALIFIED ALIEN CHILD

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3V0

AA FBU

RESTRICTED

3T-0

 

3A FBU

RESTRICTED

5T-0

 

3A FBU

RESTRICTED

 

US ADULT

 

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3N0

AA FBU

FULL-SCOPE

39-0

 

3H FBU

FULL-SCOPE

59-0

 

3H FBU

FULL-SCOPE

 

 

 

FOUR-MONTH CONTINUING

 

 

CDS FIELDS

1931(b) AID TYPE

FOUR-MONTH CONTINUING

OTHER PROGRAM REVIEW

US CHILD

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3N0

AA FBU

FULL-SCOPE

54-X

 

3H FBU

FULL-SCOPE

1931(b), 7X

BRIDGING;

MNO; HEALTHY

FAMILIES; ETC.

NOT QUALIFIED ALIEN ADULT

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3V0

AA FBU

RESTRICTED

5W-X

 

3A FBU

RESTRICTED

 

58 ONGOING

NOT QUALIFIED ALIEN CHILD

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3V0

AA FBU

RESTRICTED

5W-X

 

3A FBU

RESTRICTED

 

58 ONGOING

US ADULT

ELIG AID TYPE

PDT1 AID TYPE

FBU

M31

3N0

AA FBU

FULL-SCOPE

54-X

 

3H FBU

FULL-SCOPE

 

MNO

 


APPENDIX D

TMC CASE CONVERSIONS

 

 

EXAMPLE:  Section 1931(b)-Only case discontinuing 5/31/00 for a TMC qualifying reason. MFBU consists of 1 parent and 2 children receiving full-scope benefits and 1 parent receiving restricted benefits.

 

 

Section 1931(b)-Only ET discontinues AA FBU 5/31/00 and converts to appropriate TMC FBU

3T-0 Aid Type

3A-FBU

Effective 6/1/00

Positive Action 706

39-0 Aid Type

3H-FBU

Effective 6/1/00

Positive Action 706

Determine level of TMC benefits

 Restricted

Full-Scope

Forward closed Section 1931(b)-Only case with active TMC FBUs to TMC worker by 6/15/00

TMC worker maintains case and evaluates for further action

 



APPENDIX D

TMC COMPANION CASE CONVERSIONS

 

EXAMPLE:  Companion Section 1931(b)-Only and CalWORKs case. CalWORKs case is being discontinued 5/31/00 for a TMC qualifying reason. The CalWORKs FBU consists of two children. Section 1931(b)-Only MFBU consists of two parents. One parent receives full-scope Medi-Cal benefits and the other parent receives restricted benefits.

 

The ET who first receives the reported information notifies the companion case carrying ET via a phone call and the Memo Screen on AES.

 

*The CalWORKs ET always takes the lead on companion case conversions to TMC or Four-Month Continuing Medi-Cal.

Section 1931(b)-Only ET notates change and waits for instructions from CalWORKs TMC ET

*CalWORKs ET takes the lead

Closes CalWORKs case 5/31/00 and converts to TMC 39-0 Aid Type 70 FBU, effective 6/1/00, with Positive Action 706

Forwards closed CalWORKs case with TMC 70 FBU to CalWORKs TMC ET with a copy of the companion case memo by 6/15/00

CalWORKs TMC ET evaluates case

TMC ET instructs Section 1931(b)-Only ET to close AA FBU, effective 6/30/00, and forward any needed information. When this action is taken, the TMC ET converts 1931(b) persons to the appropriate TMC FBUs and Aid Types

TMC ET discontinues TMC 70 FBU 6/30/00 and transfers case information to Section 1931(b)-Only ET

Close 1931(b)?

Section 1931(b)-Only ET adds the persons from the CalWORKs case and maintains the case

Yes

No

Determines TMC level of benefits

Adds to TMC 39-0 Aid Type 70 FBU, effective 7/1/00, Positive Action 705 for remaining TMC months

Opens TMC 3T-0 Aid Type, 3A FBU, effective 7/1/00, Positive Action 705 for remaining TMC months

CalWORKs TMC ET maintains cases and evaluates for further action

Restricted

Full-Scope

 

 



APPENDIX E

TRANSITIONAL MEDI-CAL (TMC)

Terminated from CalWORKs or Section 1931(b)-Only

due to increased earnings from employment.

Month 1

TMC Notice is sent for 6 months of Initial TMC

Month 3

County sends

Status Report

Month 4

Did the family report timely?

Terminate TMC at the end of 6th month if he/she doesn’t have good cause

Is there still a child in the home?

 

Terminate TMC

Is the family still residing in California?

 

Terminate TMC

Continue TMC

During months

1-6, is the PWE or caretaker relative employed?

Terminate TMC if he/she doesn’t have good cause

Yes

No

No

Yes

No

Yes

No

Yes


Is there still a child in the home?

 

Terminate TMC

 

Is the average earned income less child care at or below 185% of FPL?

 

Terminate TMC

Month 7

Did the family report timely?

 

Terminate TMC

Is the family still residing in California?

 

Terminate TMC

Is a PWE or caretaker relative still employed?

Terminate TMC if he/she doesn’t have good cause

Continue TMC

Month 9

County sends Status Report

Month 6

TMC Notice and the Status Report are sent for 6 months of Additional TMC

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

 

 

 

 

 

 

 

 


 

Is there still a child in the home?

 

Terminate TMC

Is the family still residing in California?

 

Terminate TMC

Is a PWE or caretaker relative still employed?

Terminate TMC if he/she doesn’t have good cause

Continue TMC until the end of the 12th month

Month 10

Did the family report timely?

Is the average

earned income less child care at or

below 185% of the FPL?

 

Terminate TMC

 

Terminate TMC

Month 12

Evaluate persons age 19 and over for

other Medi-Cal programs.

Evaluate children for other Medi-Cal

Programs or refer to Healthy Families.

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

 

 



APPENDIX F

 

TMC QUESTIONS AND ANSWERS

 

QUESTION 1:

 

Even though TMC is no longer available to an 18-year-old not enrolled in school and expected to graduate before age 19 because he or she is not eligible for CalWORKs or Section 1931(b), should those beneficiaries who are currently receiving TMC under the old rules be terminated?

 

ANSWER 1:

 

No. Persons who do not meet the CalWORKs definition of a child may remain eligible to TMC if they were considered a child prior to entering TMC. They may remain eligible unless they are the youngest child in the home. In that case, the entire TMC family is terminated.

 

MEM Proc.

5B-11

QUESTION 2:

 

When the first year of TMC ends, is the beneficiary evaluated for Section 1931(b) again before granting the second year of TMC?

 

ANSWER 2:

 

The ET must review for changes in income or in the FBU that might make the family eligible to Section 1931(b) as applicants. The children who are not eligible for the second year of TMC may be eligible for regular Medi-Cal, a Percent Program, or they may be eligible for the Healthy Families Program.

 

 

QUESTION 3:

 

Is the family eligible for TMC if they lose CalWORKs or Section 1931(b) due to increased earnings from State Disability Insurance, or Temporary Workers Compensation?

 

ANSWER 3:

 

No. As in the current TMC Program, only an increase in earnings from actual employment can make the family eligible for the TMC Program.

 

 


QUESTION 4:

 

If a family’s income drops while receiving TMC, should counties redetermine eligibility for Section 1931(b) or CalWORKs?

 

ANSWER 4:

 

Yes. Section 1931(b) is more beneficial to the family since there are no time limits. However, the family must pass the U-Parent test if the PWE is working 100 hours or more and must meet applicant rules if they do not return to Section 1931(b) within four months.

 

 

 

 

 

 

 

 


MEM Proc.

5B-12

 

QUESTION 5:

 

If a family received CalWORKs for two months before being terminated and Section 1931(b) for two months before being ineligible due to increased earnings from employment, can they have TMC based on receiving CalWORKs or TMC for three of the last six months?

 

ANSWER 5:

 

Yes.

 

 

QUESTION 6:

 

In the second six months and the second year of TMC, do we use the limit for the entire family even if there is a 20-year-old who is not receiving TMC when comparing the TMC family’s average last three month’s earnings minus childcare deductions to 185 percent of the Federal Poverty Level?

 

ANSWER 6:

 

Yes. The family size includes everyone who is a family member in the household if they are receiving TMC or other Medi-Cal except it does not include the person who is PA or Other PA. The earned income of the other family members is also included when comparing the total to the 185 percent limit.

 

QUESTION 7:

 

If the TMC flyer is returned months after the CalWORKs or Section 1931(b) case has been terminated and it is determined that the family was terminated for increased earnings from employment, should the county process the case for TMC?

 

ANSWER 7:

 

Yes. Since TMC can be very important to families who may have no health insurance from their employer, counties should make every attempt to process TMC cases if applicable. If the family still meets the TMC eligibility criteria, they may be eligible for TMC if they are not eligible for Section 1931(b). The ET must report the TMC aid code 39 retroactively to MEDS immediately following the CalWORKs, aid code 38, or Section 1931(b) aid code when they were terminated and the family may only receive the remainder of the initial TMC period. If eligible for the next six months, they may continue.

 

 

 


QUESTION 8:

 

A 38 case opens for an 18 year-old who was discontinued from CalWORKs or Section 1931(b)-Only. Two months later, the CalWORKs or Section 1931(b)-Only case closes for the rest of the family for over income due to earnings and a TMC case is opened. Should the 18 year-old be added to the TMC case?

 

ANSWER 8:

 

No. The 18 year-old was not CalWORKs or Section 1931(b)-Only eligible and was not a member of the CalWORKs or Section 1931(b)-Only Assistance Unit (AU) the month the family was determined to be ineligible for CalWORKs or Section 1931(b)-Only. The 18 year-old, if still in the home, would have the same case number, but a separate FBU.

QUESTION 9:

 

Would a child who enters the family after TMC begins be added to the TMC case?

 

ANSWER 9:

 

Yes, if the child would have been eligible in the CalWORKs or Section 1931(b)-Only case in the month of discontinuance.

 

 

QUESTION 10:

 

If a TMC case closes and ongoing Medi-Cal needs to be evaluated, should we be using the SAWS 2 from the closed CalWORKs or Section 1931(b)-Only even though the SAWS 2 could now be over 12 months old?

 

ANSWER 10:

 

No. In this situation, use of the MC 210 RV is acceptable. The worker should also send an MC 13 for each family member.

 

QUESTION 11:

 

May an employed parent return home and be added to the TMC case with the other parent and children?

 

ANSWER 11:

 

Yes. He/she may be added if his/her income/resources would have been included in the CalWORKs or Section 1931(b) case. If he/she chooses to be added, his/her income will be counted. Once added, he/she may not be later excluded.

 

QUESTION 12:

 

May an 18-year-old child who is not enrolled in school return home and be added to the TMC unit?

 

ANSWER 12:

 

Not unless he/she would have met the definition of a child if she/he had been in the home at the time that TMC began.

 

 

QUESTION 13:

 

May undocumented parents be added to the TMC unit with their children if their citizen children were terminated from CalWORKs due to increased earnings of the PWE and the family is not eligible for Section 1931(b) even if the parents never received benefits under Section 1931(b)?

 

ANSWER 13:

 

Yes. The parents could receive restricted TMC benefits because they were members of a family who received CalWORKs and their income was used in the CalWORKs determination.

 

 

QUESTION 14:

 

May a “child” who is 19, or 20 be added to the second year of TMC with his/her parents and other siblings?

 

ANSWER 14:

 

Not unless he/she would have met the definition of a child if he/she had been in the home at the time that the Initial TMC began.

 

QUESTION 15:

 

If a family loses TMC because there was no eligible child in the household and the child returns several months later, is the family again eligible to TMC?

 

ANSWER 15:

 

The family may receive the remainder of the first year of TMC if they meet the eligibility criteria; however, they are not eligible for the second year of TMC because no family member received the entire first year of TMC.

 

 

QUESTION 16:

 

May a family be discontinued from TMC for failure to complete a request for information that is not required for the TMC Program?

 

ANSWER 16:

 

No. Redeterminations are not required during the TMC nor should the county request information or verifications that are not applicable to the TMC Program.

 

 

QUESTION 17:

 

If the stepparent with no children of his/her own is not the PWE and his/her earnings from employment cause the family to lose Section 1931(b), is the family eligible for TMC?

 

ANSWER 17:

 

Yes, if the stepparent meets the definition of a caretaker relative because he/she shares in the care and control of his/her spouse’s children. Counties are not required to verify this for TMC purposes.

 

 

QUESTION 18:

 

Is there a limit to amount of child care expenses which are necessary for the employment of the parents or spouse of a parent?

 

ANSWER 18:

 

No.

 

 

QUESTION 19:

 

If the county receives information that would cause the TMC family to lose eligibility, e.g., the earned income went above the 185 percent FPL limit in the Additional TMC Period, may the county take action to terminate the family prior to the date the TMC status report is due?

 

ANSWER 19:

 

No. Federal law only requires the family to report on specific dates and the earned income must be the average of the previous three months minus childcare expenses.

 

QUESTION 20:

 

Since there are no status reports required in the second year of TMC, may the county terminate the TMC family at any time during that year if their earned income goes above the 185 percent FPL limit?

 

ANSWER 20:

 

Yes. As long as the calculation is the same as used for the Additional TMC Period and the three-month average was not already used in a previous calculation.

 

 

QUESTION 21:

 

If the parent was terminated from Section 1931(b) and is eligible for TMC, but the child was only eligible for the MN Program with a SOC or the Percent Programs due to Sneede, is the child also eligible for TMC?

 

ANSWER 21:

 

Yes. The child may be added to the TMC case with the parent.