The purpose of this memo is to inform AIDS Drug Assistance Program (ADAP) and Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) Enrollment Workers (EW) 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 or benefits, 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 that can be covered by another payor.

Below you will find information on Medi-Cal's latest updates:

• Medi-Cal Expansion to Individuals Aged 50+
• Medi-Cal Expansion Asset Increase
  

Medi-Cal Expansion to Individuals Aged 50+

Introduction

Due to the passage of Assembly Bill 133 (AB 133), on May 1, 2022, the Department of Health Care Services (DHCS) began extending full-scope Modified Adjusted Gross Income (MAGI) Medi-Cal benefits to individuals 50 years of age or older, 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.

ADAP and PrEP-AP Policy Update

All new or re-enrolling clients aged 50 years or older, with income under 138% of the FPL, must be referred to apply for Medi-Cal at the time of their initial enrollment or re-enrollment. Please see Medi-Cal sections below for more policy information.

For undocumented clients who have concerns with applying for Medi-Cal please see scenario 9 below for guidance. If you have a client who falls into this category, and was on Emergency Medi-Cal only, as of May 1, 2022, they may have been automatically moved into the full scope MAGI Medi-Cal category already.  

Scenarios

Please review the scenarios below. For these examples, the income provided is below 138% of the FPL, which for 2022 is $18,755 for a household of one.

Scenario 1: A new undocumented client, age 50+, with income below 138% FPL, applies for ADAP.

• The EW must refer the client to Medi-Cal. While awaiting Medi-Cal determination, the new client is placed on a Temporary Access Period (TAP) and receives ADAP benefits. If the determination exceeds the 30-day TAP, please submit a Medi-Cal Eligibility Exception Request (MEER).

Scenario 2: An existing undocumented client, age 50 and older, with income below 138% FPL, re-enrolls in ADAP or one of our health insurance premium payment (HIPP) programs: Employer Based Health Insurance Premium Payment (EB-HIPP), HIPP, Medicare Part D Premium Payment (MDPP).

• 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. If the determination exceeds the 30-day TAP, please submit a MEER.

Scenario 3: A new client age 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. If the determination exceeds the 30-day TAP, please submit a MEER.

Scenario 4: An existing client age 19-64, legally present, with income below 138% of the FPL, 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. If the determination exceeds the 30-day TAP, please submit a MEER.

Scenario 5: A new client age 26-49, 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 age 26-49, undocumented, with income below 138% of FPL re-enrolls in ADAP and/or HIPP.

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

Scenario 7: A new or existing client (not on any insurance assistance program) applies for 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. If the existing client has active ADAP eligibility, disenroll from ADAP as their services are covered by Medi-Cal.

Scenario 8: An existing client enrolled in an ADAP insurance assistance program (EB-HIPP, HIPP, MDPP) applies for 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.

Scenario 9: A new or existing undocumented client is enrolling in ADAP is potentially eligible for Medi-Cal but refuses to apply or enroll in Medi-Cal.

• The EW will screen the client for comprehensive health coverage in the ADAP Enrollment System (AES) and must enter a case note indicating the client refuses to apply to Medi-Cal, and proceed with enrollment.

Medi-Cal Expansion Asset Increase

Introduction

Due to the passage of AB 133 (Chapter 143, Statutes of 2021), the Medi-Cal asset test will be eliminated for Non-MAGI Medi-Cal programs in a two-phased approach. The asset test elimination will be phased in over 2.5 years.

Phase 1: Medi-Cal Asset Limit Increase

On July 1, 2022, the DHCS increased the asset limit for Non-MAGI Medi-Cal programs. Non-MAGI programs generally provide health care for seniors, people with disabilities, and individuals who are in nursing facilities, as well as some other specialty groups. The increased asset limits will allow a larger number of applicants to become eligible for Medi-Cal benefits, and will allow qualified beneficiaries to retain a larger amount of non-exempt assets and still be eligible for Medi-Cal.

All other Non-MAGI Medi-Cal rules regarding the treatment of assets will still apply (i.e., primary home, one vehicle, household goods and personal belongings, life-insurance policy with a face value of $1,500 per person, and prepaid burial plan (unlimited if irrevocable or up to $1,500 if revocable) and burial plot). 

The new limits will be as follows:

Household Assest Limits for Non-MAGI Programs as of July 1, 2022

Note: A household size of one with assets below $130,000 will need to apply for Medi-Cal.

The Medi-Cal programs that the asset rule applies to include Aged, Blind, and Disabled, Medi-Cal with a Share of Cost, 250% Working Disabled Program, long-term care, and Medicare Savings Programs. However, the asset rule does not apply to individuals receiving Supplemental Security Income (federal program administered by the Social Security Administration) or other cash assistance such as CalFresh.

Proof of Assets in Excess of Medi-Cal Limits

The client must provide supporting documentation (i.e., current statement from a financial institutation or combination of financial institutions) showing balance exceeding the property reserve limits outlined in the table above. Note: Effective January 2024, documentation will not be required (see below).

Phase 2: Medi-Cal Asset Test Elimination

No sooner than January 1, 2024, the DHCS will eliminate the asset test entirely, expanding access to Medi-Cal for approximately 18,000 new beneficiaries and improving access to benefits for almost 2 million Californians currently on Medi-Cal.  

ADAP and PrEP-AP Policy Update

Effective July 1, 2022, all new or re-enrolling clients age 65 and older, with income under 138% of the FPL, must be referred to apply for Medi-Cal. Please see Medi-Cal sections below for more policy information.

Scenarios

Please review the scenarios below. For these examples, the income provided is below 138% of the FPL, which for 2022 is $18,755 for a household of one.

Scenario 1: A new client, age 65 and older, with income below 138% FPL and less than $130,000 in their bank account applies for ADAP.

• The 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 client, age 65 and older, with income below 138% FPL and less than $130,000 in their bank account, 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 age 65 and older with income below 138% of the FPL, household of one (1) with $150,000 in their bank account applies for ADAP.

• The client must provide supporting documentation (i.e., current statement from a financial institution) showing a balance exceeding the property reserve limits outlined in the table above. If documentation is provided showing that the client's bank account exceeds the Medi-Cal asset limit, the client will not be referred to Medi-Cal. Note: Effective January 2024, documentation will not be required.

This does not change the policy for those with non-working incomes (i.e., Social Security, pension, state disability, private disability, individuals living off assets, interest, dividends, annuities, IRA or 401K) or non-working incomes with Medicare. Since individuals with non-working  income is not from employment, they would only be subject to the asset test and should always be screened for Non-MAGI Medi-Cal.

Scenario 4: A new or existing client age 19 and older, legally present, with non-working income applies for ADAP.

• The EW must refer the client to apply for Non-MAGI Medi-Cal, if the client does not have excess assets, as they may be eligible for full-scope. While awaiting Medi-Cal determination, the client is placed on a TAP and receives ADAP benefits. If the determination exceeds the 30-day TAP, please submit a MEER.
  

Scenario 5: A new or existing client age 19 and older, legally present, on Medicare, with non-working income applies for ADAP.

• The EW must refer the client to apply for Non-MAGI Medi-Cal if the client does not have excess assets. While awaiting Medi-Cal determination, the client is placed on a TAP and receives ADAP benefits. If the determination exceeds the 30-day TAP, please submit a MEER.

Screening for Medi-Cal

Potentially eligible ADAP clients will be screened at their initial enrollment or re-enrollment for Medi-Cal. ADAP will not send separate outreach to potentially eligible clients.

Please note, existing clients who may quailify for Medi-Cal due to this extension should be screened at their next re-enrollment appointment. If a client is found to be enrolled in ADAP and Medi-Cal during secondary review, an ADAP advisor will reach out to the assigned EW to confirm that the client has been successfully enrolled in Medi-Cal before disenrolling the client from ADAP.

Undocumented clients between the ages 26-49 are not eligible for Medi-Cal currently. Therefore, their eligibility for ADAP/PrEP-AP remains the same.

How to Apply for Medi-Cal

Clients can apply for Medi-Cal through their local Medi-Cal office or online via Covered California. To apply online, clients will need to input information regarding their coverage year, zip code, household income, and household size.

Clients can also apply via MyBenefits CalWIN . Note: Not all counties are covered. 

Client is Approved for Medi-Cal – What's Next?

Clients should be dis-enrolled from ADAP, including the HIPP program, once care is established through a selected Medi-Cal provider.

Client is Deemed Ineligible for Medi-Cal

If the client is deemed ineligible, the client will need to provide ADAP/PrEP-AP a notice of action from Medi-Cal.

Unacceptable reasons for Medi-Cal ineligibility include but are not limited to:

• Failure to comply
• Client lives in a facility (such as a long term care, convalescent home, mental health facility, or jail)
• Withdrawal of application
• Loss of contact/unable to locate
• Denied reason of "Other"
• Incomplete application
• Failure to cooperate (not applicable to undocumented clients who refuse to apply to Medi-Cal)
• Loss of contact/unable to contact client.

Public Charge Frequently Asked Questions (FAQ)

State-funded programs such as this Medi-Cal expansion covered under AB 133 are not subject to public charge rules. EWs should refer to ADAP's Public Charge: FAQ (English)/Spanish) (PDF) document to address concerns regarding Public Charge and its impact on client services.

DHCS Medi-Cal Resources

• DHCS Older Adult Expansion (50+)
  
• DHCS Asset Limit Changes for Non-MAGI Medi-Cal
• DHCS Asset Limit Changes Eligibility and Enrollment Plan (PDF)
  
• Justice in Aging Medi-Cal Asset Limit Elimination and Older Adult Expansion (PDF)
  

If you have any questions regarding the information provided in this memo, please contact your OA Advisor.

Thank you,

Sharisse Kemp, MSW

ADAP Branch Chief

California Department of Public Health