Certified Enrollment Counselors FAQs
This page is intended for Certified Enrollment Counselors only.
This page is intended for Certified Enrollment Counselors only. If you need enrollment assistance, please visit www.smcgov.org/healthcoverage
Main CEC page
ACE – 65 year old – Question: When does a T-ACE member’s coverage end if she is turning 65? Does it end on the last day of the month she turns 65 or the last day of the month before her 65th birthday?
Answer: The T-ACE member’s coverage terminates on the last day of the month before they turn 65.
Answer: ACE members can apply for Medi-Cal the month before they turn 65 – their coverage will begin the month in which they turn 65.
Answer: They can arrange with admitting at time of registration or contact billing office directly.
ACE – Eligibility – Question: Is there a 3 month wait to apply for T-ACE for an individual who drops their individually purchased commercial insurance health plan, including Covered California Health Plans?
Answer: No, the 3 month waiting period only applies to individuals with employer-sponsored insurance.
- Answer: 8/13/12 Yes, patients who were offered employer sponsored insurance but chose not to enroll due to unaffordability or other reasons can apply for the ACE program. Applicants who are currently enrolled in an employer sponsored program are not eligible for ACE. Applicants who have recently dropped their employer sponsored insurance are subject to a three month wait period before enrolling in ACE, unless one of the following occurs:
- Loss or change of jobs,
- Applicant moved into an area where employer-sponsored coverage is not available,
- The employer discontinued health benefits to all employees,
- Coverage was lost because the individual providing the coverage died, legally separated, or divorced,
- Health coverage was provided under a federal Consolidated Omnibus Budget Reconciliation Act (COBRA) policy, and the COBRA coverage ended,
- The applicant reached the maximum coverage of benefits allowed in the current insurance in which he/she is enrolled.
Answer: No. Medicare patients cannot qualify for ACE, not even for dental services alone. If Medicare doesn’t cover dental, then that person could qualify for DHC. DHC does cover non-covered services when someone has another insurance plan.
Answer: The ACE member’s coverage will terminate at the end of the original coverage period.
Answer: The ACE member’s coverage will terminate at the end of the month in which the income change was reported. DHC will begin the first day of the following month.
Answer: If applicant is no longer eligible due to a change in immigration staus process in CalHEERS. CHA must send an e-mail to HPSM ACE unit requesting disenrollment due to change in status. No other action need in OeA.
Answer: If applicant is no longer eligible for ACE based on income, OEA will determine eligible for DHC. If this occurs during open enrollment or there is a life qualifying event, screen for Covered California.
Answer: No. Applicant must sign the Rights & Declaration at every application/modification.
Answer: Submit a request to HSA to re-evaluate the client’s eligibility. Include the client’s verifications with the request. If the client doesn’t have their verifications with them, advise them to submit them to HSA as soon as possible. You must notify HPSM that client must be disenrolled from ACE Fee Waiver (effective the last day of the reporting month). Write a note in CORE regarding changed immigration status and notification of HPSM.
ACE – Immigration – Question: What do we do when a client is in their ACE renewal period but reports they now have satisfactory immigration status? The client will now qualify for Covered CA. How do we assist this patient?
Answer: Assist the client with the Covered CA application.
If s/he is applying prior to the 15th of the month, then nothing further needs to be done. Do not terminate the ACE enrollment. Advise the client that they must notify HPSM once their Covered CA coverage becomes active.
If it is after the 15th of the month and it is outside of the Open Enrollment period, then ask the client if they wish to apply for Temp ACE. Be sure to advise of the $360 enrollment fee and that Temp ACE will be terminated at the end of the next month.
The other option to give the client is to not enroll in Temp ACE and use the DHC discount for any services received. If the patient decides to enroll in Temp ACE, you must send an e-mail to HPSM to request that the Temp ACE be discontinued at the end of the next month.
ACE – Immigration – Question: What do we do when a client is active on the ACE program but reports a change of satisfactory immigration status? Patient will now qualify for Covered CA. How do we assist this client?
Answer: Assist the client with the Covered CA application. Modify the OEA application to update the immigration status. This will trigger a disenrollment for the end of the month.
If s/he is applying prior to the 15th of the month, then nothing further needs to be done.
If it is after the 15th of the month, then you will need to send an e-mail to HPSM to request that they extend the ACE program for one additional month.
Answer: If a patient has been terminated from ACE due to non-compliance from Medi-Cal, when the patient returns to reapply for ACE, you CAN complete both the ACE and ER MC application at the same time, as long as the applicant submits all required verifications. You must check notes in CALWIN to ensure that the applicant is submitting all required verifications and has filled out all missing forms.
Answer: If applicant qualifies for ACE FW and Restricted Medi-Cal, OeA will route the application to Medi-Cal for Restricted MAGI Medi-Cal determination. Medi-Cal will use the OeA ACE application as the application for Restricted MAGI Medi-Cal. You can also apply for Restricted Medi-Cal in CALHEERS.
Answer: Yes, they must apply for Restricted Medi-Cal. The application will be routed to HSA through OEA.
Answer: No. ACE patients are only mailed new ID cards when there is a change of name, date of birth, when there is a break in coverage or when there is a program change.
Answer: 6/1/16 Yes. Refer to ACE Handbook, Section 8, Page 29.
• Maximum of thirty (30) days per admission
Prior authorization is required.
Answer: Uninsured San Mateo County residents are eligible if they are U.S. Citizens, Legal Permanent Residents (LPRs) or other County residents with other Satisfactory Legal Immigration status with income between 138% – 200% FPL.
Answer: Enrollees will be eligible for Temp ACE from the 1st day of the month of their application date until December 31st of the current enrollment year. Unless they end up qualifying for other public coverage before December 31st
ACE – Temp ACE – Question: Will Temp ACE be available to those who enrolled in Covered CA during open enrollment but their coverage hasn’t started yet? For example, Covered CA enrollment was completed on 2/28/16, Covered CA coverage will begin on 4/1/16. Applicant comes in on 3/10/16 because of an emergency room stay on 3/8/16.
Answer: Yes. In this example, the coverage period for Temporary ACE should be from 3/1/16 through 3/31/16. The CAA would need to notify HPSM to disenroll the participant on 3/31/16. If any visits occurred during the Covered CA Open Enrollment period, the applicant would have to apply for DHC.
Answer: Yes. Temp ACE participants may still have to pay the penalty because TempACE is not a health insurance program. Depending on individual circumstances, the participant could be eligible for an exemption from the requirement to have health insurance. If the participant is granted an exemption, they would not be subject to a tax penalty.
Answer: Yes. Any verification is acceptable as self-declaration is acceptable.
Answer: RSDI Award letters are acceptable proof of income and you can confirm the income on MEDS as well. DO NOT send patients to go home and get a current document with proof.
All Programs – Eligibility – Question: Outside of the Covered CA Open Enrollment period, when there is no Qualifying Life Event, what will U.S. citizens and LPRs be eligible for if their income does not fall between 138% – 200% FPL?
Answer - Outside of the Covered CA Open Enrollment period, when there is no Qualifying Life Event, uninsured U.S. Citizens and LPRs with income less than 138% should be assisted with a MAGI Medi-Cal application. Those who have income between 200%-400% FPL will be eligible for the Discounted HealthCare program (DHC).
Answer - No.
Answer - Yes. Any verification is acceptable as self-declaration is acceptable.
Answer - Yes. Any verification is acceptable as self-declaration is acceptable.
Answer - Both the first and the second page are required and any schedules.
Answer - Yes. Any verification is acceptable as self-declaration is acceptable.
- F19-F20: Used for OeA application started and incomplete
- F19-F10: Used for OeA ACE, HK application submitted
- This process has been automated.
Answer - No. CORE is automatically recoding to W10.
Answer - WP: ACE Fee Assistance
CP: County ACE Fee Assistance
WQ: ACE Fee Waiver
CQ: County Fee Waiver
WR: Regular ACE
CR: County Regular
Answer - Yes.
Answer - It can cover 150 days retroactively from date of service.
Answer - Make an appointment with OB/GYN and that provider will write the order for the mammogram. Patient will need to get enrolled into CDP or PACT (at OB/GYN appt or beforehand with a CHA).
Answer - Yes, if they have COBRA coverage they have to wait for it to end, or until the next Covered CA open enrollment period. Note: Not paying COBRA premium is not considered loss of coverage.
If you become eligible for COBRA coverage due to the loss of employer-sponsored insurance, you can choose coverage under COBRA, or you can use a special enrollment period to enroll in a Covered California plan. But once you enroll in COBRA, the client no longer has a qualifying event.
Covered CA – New SMC resident – Question: A client just moved to San Mateo County, currently has zero income, but will have new job in a few weeks and will make $3K per month. Can she apply and get Medi-Cal right now, then report her income when she starts the job, and transfer to APTC?
Answer - Yes, that is what you want to do so that the client can take advantage of the special enrollment period.
Answer - An applicant with non-immigrant status such as a student or work visa holder does qualify for Covered CA as they are considered “Lawfully Present”. Someone with a tourist visa (B1/B2) is not eligible for Covered CA as she or he would not be considered to be a “resident”.
Answer - Yes, they can still apply for MAGI Medi-Cal and APTC. Please note on the application that they are in the process of renewing their LPR card. You can do this in CalHEERS in the Notes section when you upload their LPR document.
Covered CA – Temp ACE – Question: Scenario: Single, U.S. citizen, lost her job and insurance at the end of June. This is a qualifying life event and she can apply for Covered CA. Her current income is $1950/mo from Unemployment. This puts her income between 139% – 400% FPL (within APTC limits) however, her income from Jan – June was $37,500. Since APTC looks at income for the entire benefit year, she would be over 400% FPL for the year and would not qualify for APTC. Can she be found eligible for Temporary ACE?
Answer - Since she currently is eligible for Covered CA, even though it is without APTC, she is not eligible for Temporary ACE. However, once 60 days has passed from her qualifying life event (loss of Minimul Essential Coverage), she will no longer be eligible for a Special Enrollment period; therefore she would at that time be eligible for Temporary ACE. Her Temporary ACE will terminate on December 31st of the year in which she applies.
Answer - Someone who is eligible for Medicare is generally not eligible for DHC. However, if someone has Medicare (or other 3rd party coverage) and qualifies as a “patient with high medical costs” then they could qualify for DHC. ”Patient with high medical costs” is defined as “Annual out-of-pocket costs incurred by the individual at SMMC that exceed 10% of the patient’s family income during the previous 12 months, or Annual out-of pocket expenses for medical care that exceed 10% of the patient’s family income. SMMC may require documentation to establish the out-of-pocket.
Answer - If patient is currently enrolled in ACE, then their bills within the past three months of the ACE coverage will be waived and visits beyond the three months will be coded DHC. You must collect the DHC enrollment form for this patient and scan it into ECW. You must write notes in CORE.
If the patient is currently not on any program and/or not interested in applying or has other insurance coverage, then the Hotline or clinic staff can refer patient to the Billing department to apply for DHC. The Billing department will assist them with the DHC manual application. If the patient is already with a CHA, the CHA can complete a manual enrollment form and scan it into ECW and write notes in CORE.
Answer - Family PACT offers limited infertility services.
Medi-Cal – Absent Parent Questionnaire – Question: An applicant is hesitant to apply for Medi-Cal because he’s worried about what will happen if he fills out the Absent Parent Questionnaire. He’s worried that if his ex-wife is contacted about child support that it will negatively impact his relationship with her and the custody arrangments that are in place. What exactly happens if they refer him to the Child Support Office?
Answer - MAGI does not require the Absent Parent Questionnaire. For Classic Medi-Cal, the Absent Parent Questionnaire is required when the linkage is absent parent and the custodial parent is applying for Medi-Cal for him/herself. If the custodial parent chooses not to provide the information, then s/he will be found ineligible for Medi-Cal but the child can still be found eligible.
Answer - For many individuals who enroll in Medi-Cal, there are no premiums, no co-payments, and no out of pocket costs. Some households will see affordable costs, such as a low monthly premium. For some Medi-Cal kids, the premium is only $13 per child. In general, individuals in Medi-Cal will get the same health benefits available through Covered California at a lower cost.
Answer - Yes. As of May 1, 2014, adults over the age of 21 in Medi-Cal are able to access dental services and receive preventive, diagnostic and restorative services. Covered benefits include:
- Examinations, radiographs or photographic images, prophylaxis and fluoride treatments
- Amalgam and composite restorations
- Prefabricated stainless steel, resin and resin window crowns
- Anterior root canal therapy
- Complete dentures, including immediate dentures
- Complete denture adjustments, repairs and relines
Answer - An adult tax dependent can file and sign their own Medi-Cal application if the tax filer is not also seeking benefits.
Example: A 55 year old woman who is claimed as a dependent on her grown son’s taxes. This woman can apply for herself.
Answer - For Classic Medi-Cal only: At least one parent is absent, deceased, unemployed or underemployed (household income less than 100% of FPL) or incapacitated (parent is disabled for 30 days or more). For there to be deprivation, the unemployed parent must be the Primary Wage Earner. When deprivation is determined, both parents in the household are linked to Medi-Cal (i.e. not just the incapacitated or unemployed parent will get Medi-Cal).
Answer - The Primary Wage Earner is the parent who has historically earned more money/has the longer work history. If it is not clear who the Primary Wage Earner is, then submit application to HSA so a Benefits Analyst can make the eligibility determination.
Answer - For MAGI, yes. For Classic MC, when someone has a short term disability (one that’s supposed to last less than 6 months) they get SDI State Disability Insurance. They are not eligible for MC unless they have minor kids in which case they would qualify through their kids because of deprivation (incapacitated parent – illness lasting 30 days or longer).
Answer - They may apply for themselves but you must follow MAGI tax household rules chart to determine household members and whose income counts.
Answer - Yes; up until the 19th birthday.
Answer - It’s not required for all applicants. While it’s technically required only for those claiming the last (16th) PRUCOL category (MC13 – Question 5), please continue to use it for all clients claiming PRUCOL as a basis for full-scope Medi-Cal, to ensure that we are providing sufficient communication to HSA regarding the basis for the PRUCOL claim. In addition to the PRUCOL form, please submit whatever documentation the client provides which demonstrates their satisfactory immigration status.
Answer - DHCS Official Website: http://www.dhcs.ca.gov/formsandpubs/forms/Pages/MCEDFormsMC00.aspx
Google the form you need.
Answer - No. Foster parents must apply on their own for Medi-Cal coverage. They cannot be added to their foster child’s application. However, if they claim their foster child or children as dependents on their tax return, then their foster children will be counted as part of their household.
Answer – Individuals that have been paroled into the United States are considered lawfully present under the ACA and are eligible for coverage through Covered California regardless of how long they have been in status. In order to be eligible for full scope Medi-Cal as PRUCOL, an individual with income below 138% FPL will need to have been paroled into the U.S. for at least one year, or expect to be here for at least one year. If they are paroled for less than a year and have income below 138%, they can qualify for Restricted MAGI Medi-Cal and ACE FW.
There are two relevant requirements: a) state residency and b) immigration status.
State residency: To meet the state residency requirements, individuals need only show that they are living in California with the intent to stay here. A parolee who has been here for a day but who intends to live here should be able to qualify as a state resident, if otherwise eligible. By contrast, a parolee who has a permanent home elsewhere and has come to California only for a short time, e.g. to visit or to get medical care, may have trouble meeting the state residency requirement.
Immigration status: Individuals who are either “qualified” immigrants or who are “permanently residing in the US under color of law (PRUCOL) meet the immigration status criteria. An individual whose parole is expected to last at least a year is a “qualified” immigrant, even if he/she has only been in the US for a couple of days. Those whose parole was granted for a shorter term (less than a year) are not “qualified” immigrants, but depending on the circumstances, may be able to show that they are PRUCOL. Again, someone who comes for a very short period and intends to leave will have trouble establishing that he/she is PRUCOL.
Answer – Individuals with Fee for Service Medi-Cal may call 916-636-1980 or 800-541-5555 for billing or provider questions.
Answer – Yes, they can still apply. A BA will confirm their legal status by running a SAVE report.
Answer – Yes.
Answer – The client remains a Lawful Permanent Resident – their status did not expire, just their LPR card. They can apply for Medi-Cal or APTC.
However, they would be considered undocumented if they had Conditional Legal Permanent status and did not renew their card.
Answer – MAGI Medi-Cal (full scope or restricted) has no Share of Cost. If their income is higher than the MAGI Medi-Cal FPL threshold, the applicant will not be eligible for MAGI Medi-Cal.
The client can apply for traditional Medi-Cal if they have linkage.
Answer – Call BEST at 1-800-223-8383. Client will need to be re-evaluated.
Answer – MEDS updates 2-3 days later.
Answer - Yes, PE covers pregnancy terminations.
Answer - To qualify for Hospital PE, applicants must:
(a) be a California resident
(b) meet income/household requirements:<
(1) Children 0-18 years of age – Income at or below 266% FPL
(2) Parents/caretaker relatives – Income at or below 109% FPL
(3) Pregnant women – Income at or below 213% FPL
(4) Former foster care children 18 to 26 years of age who received foster care on their 18th birthday – No income screening
(5) Adults 19 – 64 who are not pregnant, not enrolled in Medicare and not eligible for any group described above – Income at or below 138% FPL
Answer - Coverage begins on the date of enrollment. Coverage continues through the end of the following month. If applicant’s Medi-Cal case is denied for eligibility in the month of their HPE enrollment, they will not have coverage during the month following their enrollment.
Medi-Cal – Process – Question: Are Medi-Cal applicants under age 26 required to seek coverage from parent’s insurance plan due to new Affordable Health Care Act Mandate (both private and employer sponsored)?
Answer - No, it’s not required.
Answer - DO NOT fill out a new Single Streamlined application or complete a CalHEERs application.
(1) Fill out a Medi-Cal Add a Family Member MC 371 form for the new family member.
(2) Fill out a RFTHI form for the new family member and the primary tax filer on the application.
(3) Include the Medi-Cal case number of the existing family member on the top of the application.
(4) Email (via secure messaging) the following to HSA_verifs@smcgov.org: RFTHI forms and the MC 371 form and any supporting verifications.
Answer - Process as usual; fill out a MC371 and submit with other verifications to OeA.
Answer - HSA is currently not sending the client PRUCOL declaration documentation to ICE.
Answer - All Medi-Cal discontinuances for failure to provide the renewal packet (including required verifications) will be provided a 90-day cure period. The beneficiary has 90 days from the date of termination to provide the information needed for redetermination and potentially have their discontinuance rescinded if they are still eligible for Medi-Cal.
Medi-Cal – Residency – Question: Client has CalFresh/General Assistance in another county but is applying for health coverage in San Mateo County with a current proof of San Mateo County residency. Can we enroll him or her in health coverage or do we need to have them cancel their program in the other county first?
Answer - CHA/CAA must call the originating county with the client to update their address. This will initiate the county transfer to San Mateo. Please refer to the contact information for the Inter-County Transfers for Other Counties. Once the call has been made, the ACE FW enrollment can be completed for the client.
Answer - A 70 year old undocumented applicant with income under 138% FPL can apply for both ACE Fee Waiver and Restricted Medi-Cal via One-e-App. You will need to include the following additional verifications with the OeA application:
- MC 322
- Income and Deduction Supplement, if applicable
- Proof of Assets/Property if applicable
If the applicant is already active in ACE Fee Waiver, you can assist the applicant by filling out the Single Streamlined application and submit it through the non-pilot referral process.
Medi-Cal – Tax - Question: Scenario: a married couple. The husband works and files taxes jointly with his wife, who doesn’t work. The wife has a 19 year old child from a prior relationship. That child is listed as a dependent on the taxes of mom and her new husband. All have TPS. What should the 19 year old apply for?
Answer - OEA has an exception programmed to MAGI rules to not count the income of a step-parent for 19 and 20 year old children. The 19 year old should be evaluated first for MAGI (without step-parent’s income). If they prefer, they can apply for PRUCOL and receive full scope MAGI coverage. If income is over 138% FPL, then the 19 year old is evaluated for APTC if documented and ACE if undocumented. In this example, the 19 year old has TPS; therefore he would qualify for APTC.
Answer - They can either:
(a) notify the Medi-Cal office in their old county of residence that they have moved to a new county, or
(b) notify the Medi-Cal office in their new county of residence that they would like their Medi-Cal transferred to their new county. This is called the e-ICT process.
Answer - Classic Medi-Cal requires verification of the current savings/checking account balance. The verifications the applicants usually bring in are the bank account statements from the previous month so it wouldn’t have the current balance. Medi-Cal has forms that the client can bring to their bank to verify current balance on accounts.
Answer - Income verifications must be dated within 90 days of the application date. We request current income verification or the most recent pay stub (within 30 days if possible), which can be from the month before if they haven’t received a check yet for the current month. However, if the verification provided is not reflective of what they usually make (i.e. there is overtime or they now work less hours), then we ask for additional verification.
The only verification that is required to be from a certain month is property (must be in the application month).
Answer - No, the applicant just needs to provide their social security number. However, if HSA finds a discrepancy such as another MC applicant with the same social security # or the MC applicant provided another social security number on a previous application, then HSA might ask the applicant to provide their social security card.
Answer - For Classic MC: Form C123 is used for intake only and C338 is used for renewing. In general verifications are required at the time of application. If applicant is unable to obtain the information, the BA will provide the C123.
Answer - Both BAs and HCU staff may provide form C123 to the client to provide to their bank to request an asset verification. In the event that the client will have difficulty going to the bank directly to get the C123 filled out.
Answer - Applicants are required to apply for Medicare even if we know they do not qualify. Please take the time to do this extra step, which takes 1-2 minutes. Please do not send them to the Social Security office to spend hours to return back with a “denied” confirmation.
1. Go to Social Security website - https://www.ssa.gov/
2. Select to apply online for Medicare ONLY
3. Complete the few screens
4. Print this page and scan into Compass
Answer - 6/1/16 No.