The purpose of this memo is to inform AIDS Drug Assistance Program (ADAP) and Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Enrollment Workers about policy updates regarding Medi-Cal eligibility. 

Background

ADAP and PrEP-AP are payors of last resort. This means that ADAP/PrEP-AP are required to ensure that individuals who qualify utilize other programs such as Medi-Cal, Medicare, private insurance, or any other third party payers so that state and federal funds are not used to pay for any costs covered by another program. 

Senate Bill 104

Due to the passage of Senate Bill 104 (SB 104), on January 1, 2020, the Department of Health Care Services began extending full-scope Medi-Cal benefits to individuals 19 to 25 years of age, with income at or below 138% of the Federal Poverty Level (FPL), regardless of the individual's immigration status. Consequently, undocumented individuals meeting specific eligibility criteria (age/income) are now allowed to sign up for Medi-Cal. (SB 104)

Effective as of the date of this memo, all new, re-enrolling, or re-certifying clients between the ages of 19-25, with income under 138% of the FPL, will be referred to apply for Medi-Cal. If a client is deemed ineligible, the client will need to provide ADAP/PrEP-AP a notice of action that includes the eligibility decision from Medi-Cal. This policy, which currently applies to individuals who are lawfully present, will now be extended to clients who are undocumented, Medi-Cal policy update (PDF).

An undocumented client aged 19-25 who now qualifies for Medi-Cal at re-enrollment or re-certification will remain on ADAP/Health Insurance Premium Payment program (HIPP) with a Temporary Access Period (TAP) pending eligibility determination from Medi-Cal.

Undocumented clients over 26 are not eligible for Medi-Cal at this time. Therefore, their eligibility for ADAP/HIPP remains the same.

State-funded programs such as this Medi-Cal expansion covered under SB 104 are not subject to public charge rules. Enrollment Workers should refer to ADAP's Public Charge: Frequently Asked Questions English (PDF)/Spanish (PDF) document to address concerns regarding Public Charge and its impact on client services.

Accelerated Enrollment

July 1, 2021, Medi-Cal implemented an expedited enrollment process referred to as "Accelerated Enrollment." Accelerated Enrollment provides temporary Medi-Cal benefits to those whose Modified Adjusted Gross Income (MAGI) or other eligibility criteria is pending verification. Accelerated Enrollment will be reflected as aid code 8E in the Medi-Cal Eligibility System and clients will receive a welcome letter. Clients will remain on Medi-Cal with Accelerated Enrollment until a full county eligibility determination is completed. This accelerated process applies to anyone who applies for MAGI Medi-Cal through Covered California, either online, by phone, or mail.

The Accelerated Enrollment process will not apply to clients who apply for standard Medi-Cal through their county. Those clients will be placed on a TAP pending the eligibility determination.

Effective immediately, ADAP/PrEP-AP will no longer utilize the Medi-Cal Eligibility Exception Request (MEER) process for clients who apply through Covered California for MAGI Medi-Cal, since they will be granted Accelerated Enrollment. The MEER process will remain in place for clients who apply for standard Medi-Cal through their county.

Scenarios

Please review the scenarios below. For these examples, the income provided is below 138% of the FPL, which is $17,775 for a household of one.

Scenario 1: A new undocumented client, aged 19-25, with income below 138% FPL, applies for ADAP.

• The Enrollment Worker (EW) must refer the client to Medi-Cal. While awaiting Medi-Cal determination, the new client is placed on a TAP and receives ADAP benefits

Scenario 2: An existing undocumented client, aged 19-25, with income below 138% FPL, re-certifies or re-enrolls in ADAP or HIPP.

• The EW must refer the client to Medi-Cal. While awaiting Medi-Cal determination, the existing client is placed on a TAP and continues receiving ADAP and/or HIPP benefits.

Scenario 3: A new client aged 19-64, legally present, with income below 138% of the FPL, applies for ADAP.

• The EW must refer the client to Medi-Cal. While awaiting Medi-Cal determination, the client is placed on a TAP and receives ADAP benefits.

Scenario 4: An existing client aged 19-64, legally present, with income below 138% of the FPL, re-certifies or re-enrolls in ADAP and/or HIPP.

• The EW must refer the client to Medi-Cal. While awaiting Medi-Cal determination, the existing client is placed on a TAP and continues receiving ADAP and/or HIPP benefits.

Scenario 5: A new client over age 26, undocumented, with income below 138% of FPL applies for ADAP.

• The client is not eligible for Medi-Cal. The EW enrolls the client into ADAP.

Scenario 6: An existing client over age 26, undocumented, with income below 138% of FPL re-certifies or re-enrolls in ADAP and/or HIPP.

• The client is not eligible for Medi-Cal. The EW re-enrolls or re-certifies client for ADAP and/or HIPP.

Scenario 7: A new or existing client (not on any insurance assistance program) applies for Modified Adjusted Gross Income (MAGI) Medi-Cal through Covered California, receives a welcome letter, and has Accelerated Enrollment Medi-Cal benefits.

• The client is not eligible for ADAP. Do not enroll with a TAP or MEER.

Scenario 8: An existing client enrolled in an insurance assistance program (EB HIPP, HIPP, MDPP) applies for Modified Adjusted Gross Income (MAGI) Medi-Cal through Covered California and receives Accelerated Enrollment Medi-Cal benefits.

• The EW places the client on a TAP until the full county eligibility determination is received.

Governor's Budget 2022

The recently passed budget expands Medi-Cal eligibility for undocumented individuals over the age of 50. This policy is expected to be implemented beginning May 1, 2022. A management memo with revised policy will be released prior to implementation.

Please contact your OA Advisor if you have any questions regarding the information provided in this memo.

Thank you,