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County Eligibility & Enrollment “New Customer” Workflows County Eligibility & Enrollment Workflow Subgroup August 2, 2013 Version 3.0.

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Presentation on theme: "County Eligibility & Enrollment “New Customer” Workflows County Eligibility & Enrollment Workflow Subgroup August 2, 2013 Version 3.0."— Presentation transcript:

1 County Eligibility & Enrollment “New Customer” Workflows County Eligibility & Enrollment Workflow Subgroup August 2, 2013 Version 3.0

2 2 Page | Overview Of Content Overall Purpose of Workflow Effort To collaboratively develop “as-is” and “to-be” visual representations (e.g., Diagrams), and accompanying narratives, of a general model for “end-to-end” New Customer County Eligibility and Enrollment Workflows. County specific flows are the purview of each County. Approach Efforts reflect a collaboration between counties, DHCS, CWDA, CalHEERS, CDSS, SAWS Consortia, and other stakeholders. Approach is comprised of 4 Workflow Stages : 1.Define Initial Flow - Identify “As-Is” (Current) flows and “To-Be” (Future) health benefit flows including integration with CalFresh and CalWORKs 2.Create Flow Narrative & Correct Flow - County representatives develop flow narratives with review for “must use” elements to comply with law and regulation as well as “recommended use” elements for standardization. 3.Review and Revise with Broader Audience - CWDA sponsored review and revision of workflows and narratives face-to-face followed by edits out of meeting and some teleconference confirmation 4.Finalize for Use - Final revisions to prepare for county use (e.g., personalization to each county, training, Organizational Change Mgmt.) Scope of Flows Below  Flows contained below are focused on “Health Only” and “Health Plus” (Health, CalFresh, CalWORKs) workflows for three periods: “As-Is” (Before Oct 2013), “Early Open Enrollment” (Oct-Dec 2013), “To-Be” (Jan 2014 forward). The Visual Flows reflect a summary view of activities. Always refer to the “Narrative” documentation for actual workflow steps.

3 3 Page | “As-Is” Health Only Before Oct 2013

4 4 Page | “As-Is” Health Only (Before Oct 2013)Overview ("Level 0" Context Diagram - v3.0) Customer Entry Paths In-Person (walk-in & Appt) Phone-In SAWS On-Line Portal Mail-in & Faxed Applications Customer / Application Entry Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer / Application Entry (CW) 1 Tasks Include: Complete Request for Aid / Benefits Perform File Clearance & Create Case Process flow dependent on type of entry Advance ALL cases to process through Pre-ACA rules via SAWS Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

5 5 Page | “As-Is” Health Only (Before Oct 2013) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) Customers Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer greeted; determine need. Customers with Appts routed to EW Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. Pend for MC SOF. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance. Additional forms provided to customer (e.g., MC SOF & local forms). If interview not chosen, complete forms on paper or online at a self- service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are supported by clerical or eligibility staff. Apps are forwarded to EW for processing. Customer / Application Entry (CW) 1 Phone-In Customer greeted; determine need. County completes SAWS1 for MC on behalf of customer to Set App Date. Pend for MC SOF. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance. Additional forms mailed to customer (e.g., MC SOF & local forms). Complete forms on paper or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are supported by clerical or eligibility staff. Apps are forwarded to EW for processing. SAWS On-Line Mail–In & Faxed Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake NOTE: Customer completes and submits On-Line Application. App Date set. Staff check SAWS system queue for submitted Apps. File clearance and case creation/ registration is completed. Linked Medi-Cal applications are forwarded to eligibility staff for completion. Customer / Application Entry (CW) 1 Applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF. File clearance and case creation/ registration is completed for other Mail and FAX applications. Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. Customer / Application Entry (CW) 1 Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

6 6 Page | “As-Is” Health Only (Before Oct 2013) Eligibility & Enrollment Intake ("Level 1" Diagram - v3.0) Provide assistance with application forms, if needed. Collect MC SOF to complete application. Verify Data, as required. Enter data into SAWS, as required, and compare to known 3rd party info. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required for MC, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 EW reviews case & amends NOA if required. MC NOA Sent to Customer by SAWS. Manual Mailing of NOA is optional. Benefit Cards Created & Mailed to Customer automatically. If immediate medical attention is needed, print temporary BIC. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Refer Eligible Customers to HCO for Plan Selection for 2-Plan and GMC counties. COHS counties enroll Eligible Customers into their county’s managed care plan. Process or refer for other county medical services (e.g., LIHP, CMSP). Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Submit to SAWS for Pre-ACA rules eligibility determination. Eligible / Ineligible for MC. Pended status until further data/verifications are provided. Eligibility & Enrollment Intake Customer/ Application Entry Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions 1

7 7 Page | “To-Be” Health Only January 2014

8 8 Page | “To-Be” Health Only (Jan 2014)Overview ("Level 0" Context Diagram - v3.0) Customer Entry Paths In-Person (walk-in & Appt) Phone-In Warm Hand-offs (Transfer from Covered CA) SAWS On-Line Portal & e-Referrals Mail-in & Faxed Applications SAWS On-Line includes Web Link to CalHEERS Customer / Application Entry Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer / Application Entry (CW/EW) Customer / Application Entry (CW/EW) 1 Tasks Include: Complete Request for Aid / Benefits Process flow dependent on type of entry Perform File Clearance & Create Case Advance ALL cases to process through ACA rules via SAWS Non-MAGI cases will process through pre-ACA rules via SAWS NOTE: Other “To-Be” changes exist in E&E Intake detail. See E&E Intake Level 1 Diagram Summary Only – Read Narrative for Important Detail ** Changes from “As-Is” Health Only flow in Blue ItalicsEW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

9 9 Page | “To-Be” Health Only (Jan 2014) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) NOTE: Customers with SSApps will be processed as “Health Only” need. Customer greeted; determine need. Customers with Appts routed to EW. Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance. Should be same day. Provide SSApp for MC need and assist customer understanding if needed. Additional forms provided to customer, as needed (e.g., Non-MAGI request). If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are directed to clerical or eligibility staff for support. Apps are forwarded to EW for processing. Customer greeted; determine need. County completes SAWS1 for MC on behalf of customer to Set App Date. File clearance and case creation/ registration is completed. Complete SSApp. over phone, if possible by transfer to EW. Schedule Appt for same day/future assistance, if necessary. Should be same day. Provide SSApp for MC need and assist customer understanding if needed. Pend for MC SOF (e.g., SSApp) if EW cannot continue initial call. Additional forms provided to customer, as needed (e.g., Non-MAGI request). If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are directed to clerical or eligibility staff for support. Apps are forwarded to EW for processing. ** Changes from “As-Is” Health Only flow in Blue Italics Customers Customer / Application Entry (CW) Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer / Application Entry (CW) 1 Phone-In SAWS On-Line & e-Referrals Mail–In & Faxed Customer / Application Entry (CW) Customer / Application Entry (CW) 1 Customer / Application Entry (EW) 1 Warm Handoff (Transfers) NOTE: Customer completes and submits On-Line Application. App Date set. Referral for a Non-MAGI needs also sent by CalHEERS to SAWS work queue. Staff check SAWS system queue for submitted Apps. & e-Referrals County completes SAWS1 for Non- MAGI MC referral on behalf of customer to Set App Date. Non-MAGI forms are mailed to the customer. File clearance and case creation/ registration is completed. Linked MC Apps are then forwarded to eligibility staff for completion. Non-MAGI Apps are pended for SOF. Customer greeted; determine need. County completes SAWS1 for MC on behalf of customer to Set App Date. File clearance and case creation/ registration is completed. Complete App. over phone, if possible (step to P2) Schedule Appt for same day/future assistance, if required. Pend for MC SOF if SSApp cannot be completed with customer. Additional forms provided to customer, as needed. If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. NOTE: SSApps will be processed as “Health Only” need. Applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF. File clearance and case creation/ registration is completed for other Mail and FAX applications. Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake Customer / Application Entry (CW) Customer / Application Entry (CW) 1 SAWS On-Line Web Link to CalHEERS Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

10 10 Page | “To-Be” Health Only (Jan 2014) Eligibility & Enrollment Intake ("Level 1" Diagram - v3.0) Provide assistance with application forms, if needed. Collect IAP SOF to complete SSApp or Non-MAGI SOF, as required. Verify Data, as required. Enter data into SAWS, as required. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required for MC, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 MAGI Notices are sent to SAWS to be mailed out once determination has been finalized by the county EW. Non-MAGI MC Notices are generated by SAWS APTC/CSR Notices are generated by CalHEERS MC NOA Sent to Customer by SAWS. Manual Mailing of NOA is optional. Benefit Cards Created & Mailed to Customer automatically. NOTE: Support for adding comments to MAGI/APTC-CSR NOAs is not supported. Submit to SAWS for MAGI/APTC rules (via CalHEERS BRE) and Non-MAGI rules Eligible / Ineligible for MAGI Medi-Cal Eligible / Ineligible for APTC/CSR Eligible / Ineligible for Non-MAGI Medi-Cal Pended status until further data/verifications are provided. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO/EW) 7 EW can assist with APTC plan choice for Exchange eligibles. Customers choosing unsubsidized health coverage may be assisted by EW with plan selection via CalHEERS, if assistance is required. MC Through March Refer Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. MC April 2014 Forward... Assist customers with plan selection, as requested or required via CalHEERS. Advise customers to Pay Premium to Receive Benefit, if applicable Refer Eligible Non-MAGI Customers to HCO for counties with more than 1 plan choice. Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer/ Application Entry Initiate Non-MAGI Medi-Cal App if Denied for MAGI and Qualifiers Exist or if requested by customer. Process or refer for other county medical services (e.g., CMSP). Offer customer unsubsidized health insurance coverage as an option. Summary Only – Read Narrative for Important Detail ** Changes from “As-Is” Health Only flow in Blue Italics EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions 1

11 11 Page | “To-Be” Health Only Oct-Dec 2013

12 12 Page | “To-Be” Health Only (Oct-Dec 2013)Overview ("Level 0" Context Diagram - v3.0) Customer Entry In-Person (walk-in & Appt) Phone-In Warm Handoff (Transfers) from Covered CA SAWS On-Line Portal & e-Referrals Mail-in & Faxed Applications SAWS On-Line Web Link to CalHEERS Customer / Application Entry Eligibility & Enrollment Intake Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Customer / Application Entry (CW/EW) 1 Tasks Include Determine Customer Need & Choice of MC Now or Jan 1 Complete Request for Aid / Benefits Process flow dependent on type of entry Advance “Now” cases to process through Pre-ACA rules via SAWS Advance “Later” cases to process through ACA rules via CalHEERS NOTE: Other “To-Be” changes exist in E&E Intake detail. See E&E Intake Level 1 Diagram Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Medi-Cal “Now” Path Medi-Cal “Later” (Jan 1) Path Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions ** Changes from “As-Is” Health Only flow in Blue Italics

13 13 Page | “To-Be” Health Only (Oct-Dec 2013) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) NOTE: Customers with SSApps will be processed as “Health Only - Later” need. Customer greeted; determine need & Choice of MC Now or Later (Jan1). Customers with Appts routed to EW Customers needing assistance are supported by clerical or eligibility staff. If MC Now... Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance. Assist Client w/ MC210 or provide App Pkg, if appropriate. Additional forms provided to customer (e.g., MC SOF & local forms). If assistance not chosen, complete paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Apps are forwarded to EW for processing. If MC Later (Jan 1)... The customer is provided SSApp to complete. Schedule Appt for same day/future assistance. Should be same day. The customer is routed to designated eligibility staff for CalHEERS processing. Customers Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer / Application Entry (CW) 1 Phone-In SAWS On-Line & Referrals Mail–In & Faxed Customer / Application Entry (CW) 1 Customer / Application Entry (EW) 1 Warm Handoff (Transfers) Customer greeted; Choice of “Health Only” MC “Later” (Jan 1) is presumed. County completes SAWS1 for MC on behalf of customer to Set App Date. Assist client in CalHEERS with application and determination (jump to E&E Intake). Schedule Appt for same day/future assistance, if required. Pend for MC SOF if SSApp cannot be completed with customer. If a Non-MAGI App is requested or indicated, that need is captured on the SSApp and managed as a referral If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake Customer greeted; determine need & Choice of MC Now or Later (Jan1). Customers needing assistance are supported by clerical or eligibility staff. If MC Now... Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance. Assist Client w/ MC210 or provide App Pkg, if appropriate. Additional forms provided to customer (e.g., MC SOF & local forms). If assistance not chosen, complete paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Apps are forwarded to EW for processing. If MC Later (Jan 1)... Complete SSApp. over phone, if possible by transfer to designated eligibility staff for CalHEERS processing. Schedule Appt for same day/future assistance, if necessary. The customer is provided with SSApp to complete if phone assist not accepted or possible. Customer / Application Entry (CW) 1 NOTE: Customer completes and submits On-Line Application. App Date set.. Referrals for a Non-MAGI need are in CalHEERS work queue. NOTE: On-Line Apps are assumed to be Health “Now” Apps. CalHEERS link provided for “Later” Apps. Staff check SAWS system queue for submitted Apps. Staff check CalHEERS work queue for Non-MAGI referrals. County completes SAWS1 for Non- MAGI MC referral on behalf of customer to Set App Date. Non-MAGI forms are mailed to the customer. File clearance and case creation/ registration is completed. Linked Medi-Cal applications are then forwarded to eligibility staff for completion and pended for Non- MAGI SOF. NOTE: SSApps will be processed as “Health Only” MC “Later” need. Applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF File clearance and case creation/ registration is completed for other Mail and FAX applications. Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions ** Changes from “As-Is” Health Only flow in Blue Italics SAWS On-Line Web Link to CalHEERS

14 14 Page | “To-Be” Health Only (Oct-Dec 2013) Eligibility & Enrollment Intake – 2 Paths ("Level 1" Diagram - v3.0) Provide assistance with application forms, if needed. Collect MC SOF to complete application. Verify Data, as required. Enter data into SAWS, as required, and compare to known 3rd party info. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required for MC, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 EW Reviews Case & Comments if required. Pre-ACA MC NOA Sent to Customer by SAWS. Manual Mailing of NOA is optional. Benefit Cards Created & Mailed to Customer automatically. If immediate medical attention is needed, print temporary BIC. Submit to SAWS for Pre-ACA rules. Eligible / Ineligible for Pre-ACA MC. Pended status until further verifications are provided. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Refer Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. COHS counties enroll Eligible Customers into their county’s managed care plan. Process or refer for other county medical services (e.g., LIHP,CMSP). If Ineligible for Pre-ACA MC, route to Jan 1 Path using CalHEERS (P-3) Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Provide assistance with application forms, if needed. Collect IAP SOF (SSApp) to complete application Verify Data, as required. Enter data into CalHEERS, as required. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required for MC, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 ACA Medi-Cal or APTC/CSR NOA sent by CalHEERS. Manual Mailing of NOA is optional. Benefit Cards Created & Mailed to Customer automatically. Submit to CalHEERS for ACA rules. Eligible / Ineligible for MAGI MC or APTC/CSR. Pended status until further verifications are provided. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Refer MC Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. Others are auto enrolled. Assist APTC/CSR eligibles with Plan Selection via CalHEERS. Assist unsubsidized health insurance customers with Plan Selection via CalHEERS. If denied for MAGI/APTC-CSR refer to “Now” Path if Qualifiers Exist or if requested by customer. Process or refer for other county medical services (e.g., LIHP,CMSP). Offer customer unsubsidized health insurance coverage as an option. Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake - Medi-Cal “Later” (Jan 1 st ) Path (Uses CalHEERS) Eligibility & Enrollment Intake – Medi-Cal “Now” Path (Uses SAWS) Customer/ Application Entry EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions Summary Only – Read Narrative for Important Detail 1 ** Changes from “As-Is” Health Only flow in Blue Italics

15 15 Page | “As-Is” Health Plus Before Oct 2013

16 16 Page | “As-Is” Health Plus (Before Oct 2013)Overview ("Level 0" Context Diagram - v3.0) Customer Entry Paths In-Person (walk-in & Appt) Phone-In SAWS On-Line Portal Mail-in & Faxed Applications Customer / Application Entry Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer / Application Entry (CW) 1 Tasks Include: Complete Request for Aid / Benefits Perform File Clearance & Create Case Process flow dependent on type of entry Advance ALL cases to process through Pre-ACA rules via SAWS Supports CalFresh & CalWORKs Flows ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

17 17 Page | “As-Is” Health Plus (Before Oct 2013) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) Customer greeted; determine need. For Health Plus CalFresh w/ Pilot Program County completes SAWS1 for MC and CalFresh on behalf of customer to set App Date. Pend for MC SOF. File clearance and case creation/ registration is completed. Apps are forwarded to EW for processing. For other Health Plus Options Info provided to customer on how to apply for CalF/CalW. Schedule Appt for same day/future assistance and CalF/CalW interview. Additional forms mailed to customer (e.g., MC SOF, SAWS2, & local forms). Complete and return forms In-Person, by FAX, Mail, or on-line. Customers needing assistance are supported by clerical or eligibility staff. Customers Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer / Application Entry (CW) 1 Phone-In SAWS On-Line Mail–In & Faxed Customer / Application Entry (CW) 1 1 NOTE: Customer completes and submits On-Line Application. App Date set. Staff check SAWS system queue for submitted Apps File clearance and case creation/ registration is completed. Set Appt for CalF/CalW after case created. Forward to Customer Service to set CalF/CalW interview Appt. Mail-In applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF. File clearance and case creation/ registration is completed for other Mail and FAX applications Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake Customer greeted; determine need. Customers with Appts routed to EW Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. Pend for MC SOF. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance and CalF/CalW interview. Additional forms provided to customer (e.g., MC SOF, SAWS 2, & local forms). If interview not chosen, complete forms on paper or online at a self- service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are supported by clerical or eligibility staff. Apps are forwarded to EW for processing. ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

18 18 Page | “As-Is” Health Plus (Before Oct 2013) Eligibility & Enrollment Intake ("Level 1" Diagram - v3.0) Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required, if provided on request. Resolve Conditional or Pending States. If Ineligible for CalW, evaluate for MC. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 EW Reviews Case & Comments if required. NOAs Sent to Customer by SAWS. Manual Mailing of NOA is optional. Establish benefit payment types for CalF/CalW. Benefit Cards Created & Mailed to Customer automatically. Submit to SAWS when sufficient for at least 1 benefit. Eligible/Ineligible for MC/ CalF/ CalW. Pended status until further data/verifications are provided. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Refer Eligible Customers to HCO for Plan Selection for 2-Plan or GMC counties. COHS counties enroll Eligible Customers into their county’s managed care plan. Process or refer for other county medical services (e.g., LIHP). If Ineligible for CalW, evaluate for MC in P4. May refer the customer to other community resources, if denied for CalWORKs and/or CalFresh. Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Provide assistance with application forms, if needed. Collect SOF to complete application. Interview for SOF Info (CalW & CalF). Verify Data, as required. Enter data into SAWS, as required, and compare to known 3rd party info. Customer/ Application Entry ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail 1 EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

19 19 Page | “To-Be” Health Plus January 2014 DRAFT

20 20 Page | “To-Be” Health Plus (Jan 2014)Overview ("Level 0" Context Diagram - v3.0) Customer Entry Paths In-Person (walk-in & Appt) Phone-In Warm Hand-offs (Transfer from Covered CA) SAWS On-Line Portal Mail-in & Faxed Applications SAWS On-Line Web Link to CalHEERS Customer / Application Entry Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer / Application Entry (CW/EW) Customer / Application Entry (CW/EW) 1 Tasks Include: Complete Request for Aid / Benefits Process flow dependent on type of entry Perform File Clearance & Create Case Advance ALL cases to process through ACA rules via SAWS Supports CalFresh & CalWORKs Flows NOTE: Other “To-Be” changes exist in E&E Intake detail. See E&E Intake Level 1 Diagram ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

21 21 Page | “To-Be” Health Plus (Jan 2014) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) NOTE: Customers with SSApps will be processed as “Health Only” need. Customer greeted; determine need. Customers with Appts routed to EW. Customer directed to complete/ submit SAWS1 to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance and CalF/CalW interview. Should be same day. Additional forms provided to customer, as needed (e.g., Non-MAGI request). If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are directed to clerical or eligibility staff for support. Apps are forwarded to EW for processing. Customers Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer / Application Entry (CW) 1 Phone-In SAWS On-Line & e Referrals Mail–In & Faxed Customer / Application Entry (CW) 1 Customer / Application Entry (EW) 1 Customer / Application Entry (CW) 1 Warm Handoff (Transfers) Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake Customer greeted; determine need For Health Plus CalF County completes SAWS1 for MC on behalf of customer to set App Date. Pend for MC SOF. File clearance and case creation/ registration is completed. Complete SSApp. over phone, if possible by transfer to EW. Schedule Appt for same day/future assistance and CalF interview. Provide SSApp for MC need and assist customer understanding if needed. Pend for MC SOF (e.g., SSApp) if EW cannot continue initial call. Additional forms provided to customer, as needed (e.g., Non-MAGI request). If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Customers needing assistance are directed to clerical or eligibility staff for support. Apps are forwarded to EW for processing. For Health Plus CalW or CalW & CalF Refer to narrative. Customer cannot initiate a CalWORKs app over the phone. NOTE: Customers through this door will be processed as “Health Only” need. Other benefits managed as referrals. Customer greeted; determine need County completes SAWS1 for MC on behalf of customer to set App Date. Pend for MC SOF. File clearance and case creation/registration is completed. Complete App. over phone, if possible (step to P2) Schedule Appt for same day/future assistance. Pend for MC SOF if SSApp cannot be completed with customer. Additional forms provided to customer, as needed. If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. NOTE: Customer completes and submits On-Line Application. App Date set. Referral for a Non-MAGI, CalF, & CalW needs also sent by CalHEERS to SAWS work queue. Staff check SAWS system queue for submitted Apps. & e-Referrals County completes SAWS1 for Non- MAGI MC referral on behalf of customer to Set App Date. Non-MAGI and SAWS Plus forms are mailed to the customer, as needed. File clearance and case creation/ registration is completed. Linked MC Apps are then forwarded to eligibility staff for completion. Non-MAGI Apps are pended for SOF. NOTE: SSApps will be processed as “Health Only” need. Applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF. File clearance and case creation/ registration is completed for other Mail and FAX applications. Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. SAWS On-Line Web Link to CalHEERS ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

22 22 Page | “To-Be” Health Plus (Jan 2014) Eligibility & Enrollment Intake ("Level 1" Diagram - v3.0) Provide assistance with application forms, if needed. Collect IAP SOF to complete SSApp or Non-MAGI SOF, as required. Interview for CalF/CalW SOF Verify Data, as required. Enter data into SAWS, as required. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required for any benefit Resolve Conditional or Pending States. Enter data into SAWS, as required. See Narrative for CalW/CalF processing rules. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 MAGI Notices are sent to SAWS to be mailed out once determination has been finalized by the county EW. Non-MAGI MC & CalF/CalW Notices are generated by SAWS APTC/CSR Notices are generated by CalHEERS MC NOA Sent to Customer by SAWS. Manual Mailing of NOA is optional. Establish benefit payment types for CalF/CalW. Benefit Cards Created & Mailed to Customer automatically. NOTE: Support for adding comments to MAGI/APTC-CSR NOAs is not supported. Submit to SAWS when sufficient for at least 1 benefit Eligible / Ineligible for MAGI Medi-Cal Eligible / Ineligible for APTC/CSR Eligible / Ineligible for CalF/CalW Eligible / Ineligible for Non-MAGI Medi-Cal Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 EW can assist with APTC plan choice for Exchange eligibles. Customers choosing unsubsidized health coverage may be assisted by EW with plan selection via CalHEERS, if assistance is required. MC Through March Refer Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. MC April 2014 Forward... Assist customers with plan selection, as requested or required via CalHEERS. Advise customers to Pay Premium to Receive Benefit, if applicable Refer Eligible Non-MAGI Customers to HCO for counties with more than 1 plan choice. Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake Customer/ Application Entry ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail 1 EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions Initiate Non-MAGI Medi-Cal App if Denied for MAGI and Qualifiers Exist or if requested by customer. Process or refer for other county medical services (e.g., CMSP). Offer customer unsubsidized health insurance coverage as an option. May refer the customer to other community resources, if denied for CalWORKs and/or CalFresh.

23 23 Page | “To-Be” Health Plus Oct-Dec 2013

24 24 Page | “To-Be” Health Plus (Oct-Dec 2013)Overview ("Level 0" Context Diagram - v3.0) Customer Entry In-Person (walk-in & Appt) Phone-In Warm Hand-offs (Transfer from Covered CA) SAWS On-Line Portal Mail-in & Faxed Applications SAWS On-Line Web Link to CalHEERS Customer / Application Entry Eligibility & Enrollment Intake Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Customer / Application Entry (CW/EW) 1 Tasks Include Determine Customer Need & Choice of MC Now or Jan 1 Complete Request for Aid / Benefits Process flow dependent on type of entry Advance “Now” health cases to process through Pre-ACA rules via SAWS Advance “Later” health cases to process through ACA rules via CalHEERS Supports CalFresh & CalWORKs Flows NOTE: Other “To-Be” changes exist in E&E Intake detail. See E&E Intake Level 1 Diagram Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW/FI) Send NOAs & Benefit Card(s) (EW/FI) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Medi-Cal “Now” Path Medi-Cal “Later” (Jan 1) Path ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions

25 25 Page | “To-Be” Health Plus (Oct-Dec 2013) Customer/Application Entry by Access Path ("Level 1" Diagram - v3.0) Customers Customer / Application Entry (CW) 1 In-Person / In-Person Appt Customer / Application Entry (CW) 1 Phone-In SAWS On-Line & Referrals Mail–In & Faxed Customer / Application Entry (CW) 1 Customer / Application Entry (EW) 1 Customer / Application Entry (CW) 1 Phone-In Transfers Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 E&E Intake ** Changes from Health Only “As-Is” flow in Blue Italics Summary Only – Read Narrative for Important Detail EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions NOTE: Customers with SSApps will be processed as “Health Only - Later” need. Customer greeted; determine need & Choice of MC Now or Later (Jan1). Customers with Appts routed to EW Customers needing assistance are supported by clerical or eligibility staff. If MC Now... Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance and CalF/CalW interview. Assist Client w/ MC210 or provide App Pkg, if appropriate. Additional forms provided to customer (e.g., MC SOF & local forms). If assistance not chosen, complete paper forms or online at self-service portal. Return forms by FAX, Mail, on-line, or in- person. Apps are forwarded to EW for processing. If MC Later (Jan 1)... The customer is provided SSApp to complete. Schedule Appt for same day/future assistance. Should be same day. The customer is routed to designated eligibility staff for CalHEERS processing. Customer greeted; determine need & Choice of MC Now or Later (Jan1). Customers needing assistance are supported by clerical or eligibility staff. If MC Now... Customer directed to complete/ submit MC forms (e.g., SAWS1) to set App Date. File clearance and case creation/ registration is completed. Schedule Appt for same day/future assistance and CalF/CalW interview. Assist Client w/ MC210 or provide App Pkg, if appropriate. Additional forms provided to customer (e.g., MC SOF & local forms). If assistance not chosen, complete paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. Apps are forwarded to EW for processing. If MC Later (Jan 1)... Complete SSApp. over phone, if possible by transfer to designated eligibility staff for CalHEERS processing. Schedule Appt for same day/future assistance, if necessary. The customer is provided with SSApp to complete if phone assist not accepted or possible. If CalF and MC and Jan 1 choice … Jump to E&E Intake to follow “Jan 1” path with CalHEERS Customer greeted; Choice of “Health Only” MC “Later” (Jan 1) is presumed. County completes SAWS1 for MC on behalf of customer to Set App Date. Assist client in CalHEERS with application and determination (jump to E&E Intake). Schedule Appt for same day/future assistance, if required. Pend for MC SOF if SSApp cannot be completed with customer. If a Non-MAGI App is requested or indicated, that need is captured on the SSApp and managed as a referral If assistance not chosen, customer completes paper forms or online at a self-service portal. Return forms by FAX, Mail, on-line, or in-person. NOTE: Customer completes and submits On-Line Application. App Date set.. Referrals for a Non-MAGI need are in CalHEERS work queue. NOTE: On-Line Apps are assumed to be Health “Now” Apps. CalHEERS link provided for “Later” Apps. Staff check SAWS system queue for submitted Apps. Staff check CalHEERS work queue for Non-MAGI referrals. County completes SAWS1 for Non- MAGI MC referral on behalf of customer to Set App Date. Non-MAGI forms are mailed to the customer. File clearance and case creation/ registration is completed. Linked Medi-Cal applications are then forwarded to eligibility staff for completion and pended for Non- MAGI SOF. Set Appt for CalF/CalW interview after case created. NOTE: SSApps will be processed as “Health Only” MC “Later” need. Applications requested by phone (case already created) are screened and forwarded to E&E Intake. If incoming App is SAWS1 only then App is pended for SOF File clearance and case creation/ registration is completed for other Mail and FAX applications. Schedule Appt for same day/future assistance. Apps are forwarded to EW for processing. SAWS On-Line Web Link to CalHEERS

26 26 Page | “To-Be” Health Plus (Oct-Dec 2013) Eligibility & Enrollment Intake – 2 Paths ("Level 1" Diagram - v3.0) Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Process or refer for other county medical services (e.g., LIHP). If Ineligible for Pre-ACA MC, route to “Later” Path using CalHEERS. Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 ** Changes from Health Only “As-Is” flow in Blue Italics Provide assistance with application forms, if needed. Collect IAP SOF (SSApp) to complete application. Verify Data, as required. Enter CalF/CalW request, if applicable (referral via CalHEERS). Enter data into CalHEERS for Health and SAWS for CalF/CalW, as required. Data Collection/ Assistance (EW) Data Collection/ Assistance (EW) 2 Run Eligibility (EW) Run Eligibility (EW) 3 Gather additional post-run Data if required, if provided on request. Resolve Conditional or Pending States. Enter data into SAWS, as required. Re-Submit to Run Eligibility process. Additional Data Collection/Verification (EW) Additional Data Collection/Verification (EW) 4 Submit to CalHEERS for ACA health rules; Submit to SAWS for CalF/CalW rules Eligible / Ineligible for MAGI MC, APTC/CSR, CalF and/or CalW. Pended status until further verifications are provided. Send NOAs & Benefit Card(s) (EW) Send NOAs & Benefit Card(s) (EW) 6 Select Health Plan (HCO) 7 Ineligible Post-Processing (EW) Ineligible Post-Processing (EW) 5 Eligibility & Enrollment Intake - Medi-Cal “Later” (Jan 1 st ) Path (Uses CalHEERS & SAWS) Eligibility & Enrollment Intake – Medi-Cal “Now” Path (Uses SAWS) Customer/ Application Entry Summary Only – Read Narrative for Important Detail 1 EW = Eligibility Worker CW = Clerical Worker FI = Fiscal Intermediary MC = Medi-Cal SOF = Statement of Facts HCO = Health Care Options NOA = Notice of Action ACA = Affordable Care Act CalW = CalWORKs CalF = CalFresh IAP = Insurance Affordability Programs APTC/CSR = Advance Premium Tax Credit/Cost Sharing Reductions Provide assistance with application forms, if needed. Collect MC SOF to complete application. Interview for CalF/CalW SOF. Verify Data, as required. Enter data into SAWS, as required, and compare to known 3rd party info. Submit to SAWS for Pre-ACA rules when sufficient for at least 1 benefit. Eligible / Ineligible for Pre-ACA MC, CalF, & CalW. Pended status until further verifications are provided. Refer Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. COHS counties enroll Eligible Customers into their county’s managed care plan. EW Reviews Case & Comments if required. Pre-ACA MC & CalF/CalW NOAs Sent to Customer by SAWS. Manual Mailing of NOA is optional. Establish benefit payment types for CalF/CalW. Benefit Cards Created & Mailed to Customer automatically. If immediate medical attention is needed, print temporary BIC. If denied for MAGI/APTC-CSR refer to “Now” Path if Qualifiers Exist or if requested by customer. Process or refer for other county medical services (e.g., LIHP,CMSP). Offer customer unsubsidized health insurance coverage as option. EW Reviews Case & Comments if required NOTE: Support for adding comments to MAGI/APTC-CSR NOAs is not supported. ACA Medi-Cal or APTC/CSR NOA sent by CalHEERS. Manual Mailing of NOA is optional. Establish benefit payment types for CalF/CalW. Benefit Cards Created & Mailed to Customer automatically. Refer MC Eligible Customers to HCO for Plan Selection for counties with more than 1 plan choice. Others are auto enrolled. Assist APTC/CSR eligibles with Plan Selection via CalHEERS. Assist unsubsidized health insurance customers with Plan Selection via CalHEERS.


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