Rfthi Tax Form – Fill Out and Use This PDF

	State of California—Health and Human Services Agency
	Department of Health Care Services
zyxwvutsrqponmlkjihDirectorGovernor
TOBY DOUGLAS	EDMUND G. BROWN JR.
Date:	February 10, 2014

TO: ALL COUNTY WELFARE DIRECTORS Letter No. 14­03

ALL COUNTY ADMINISTRATIVE OFFICERS

ALL COUNTY MEDI­CAL PROGRAM SPECIALISTS/LIAISONS

ALL COUNTY HEALTH EXECUTIVES

ALL COUNTY MENTAL HEALTH DIRECTORS

SUBJECT: 2014 Renewals: Converting Pre­ACA Medi­Cal Beneficiaries to MAGI Medi­Cal

The Department of Health Care Services (DHCS) is providing guidance as a result of Assembly Bill (AB) x1 1, Chapter 3, Statutes of 2013, as well as recent guidance provided by the federal Centers for Medicare & Medicaid Services (CMS) on the Affordable Care Act of 2010 (ACA). This letter is to provide the Statewide Automated Welfare Systems (SAWS) and counties with policy guidance.

This guidance is focused on implementing Medi­Cal annual redeterminations to convert beneficiaries from Pre­ACA (Pre­Affordable Care Act) Medi­Cal to Modified Adjusted Gross Income (MAGI) Medi­Cal in 2014.

This ACWDL overrides previous ACWDLs on the Medi­Cal annual renewal process including ACWDLs 06­16, 06­17, and 11­23.

Background

As prescribed in Welfare and Institutions Code (WIC) Section 14005.37, the Medi­Cal annual redetermination process for those individuals subject to Medi­Cal benefits on the basis of MAGI, shall be streamlined and simplified. Medi­Cal beneficiaries will have their annual redeterminations conducted via an “ex parte” review of available information to the greatest extent possible.

An “ex parte” review refers to an upfront review of current beneficiary data and information by the eligibility worker before asking the beneficiary for additional data. An ex parte review may be able to provide for an upfront renewal of Medi­Cal benefits without a beneficiary ever having to complete an annual redetermination packet. Such action furthers the process principles of being streamlined and simplified.

Medi­Cal Eligibility Division

1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899­7417

(916)552­9430 phone, (916) 552­9477 fax Internet Address: www.dhcs.ca.gov

All County Welfare Directors Letter No.: 14­03

Page 2

February 10, 2014

While in the future, the ex parte review is to occur prior to seeking any information from the beneficiary, and beneficiaries from whom information is needed will receive a pre­ populated redetermination form, a slightly different process must be followed for existing Pre­ACA Medi­Cal beneficiaries whose annual redeterminations are due after January 2014. For these Pre­ACA Medi­Cal beneficiaries, the first ex parte review process would automatically fail due to the fact that there is not enough information known about the beneficiary’s tax household and tax income to conduct a MAGI eligibility determination. To determine MAGI eligibility for pre­ACA beneficiaries, current information about federal tax household and income is needed.

Specifically, MAGI Medi­Cal is based upon IRS tax rules, but IRS information is not known for Pre­ACA Medi­Cal beneficiaries. Therefore, counties are required to collect additional information on Pre­ACA Medi­Cal beneficiaries in order to complete the beneficiary’s 2014 annual redetermination. Many Medi­Cal beneficiaries are not required to file taxes because their income is so low. For those beneficiaries, the state still needs to determine the MAGI household and determine current income.

Medi­Cal Annual Redetermination Process Will Begin May 2014

The Medi­Cal annual redetermination process, as prescribed below in this letter, shall begin for individuals with redeterminations due in May 2014. Counties shall ensure they do not process Medi­Cal annual redeterminations for individuals who would have otherwise been due for redetermination from January 2014 through April 2014. Those who had redeterminations due from January through April will be moved according to the below schedule.

Beginning with annual redeterminations due in May 2014, Medi­Cal annual redeterminations for 2014 only will be processed according to the following timeline:

ｸJanuary and May annual redeterminations in May

ｸFebruary and June annual redeterminations in June

ｸMarch and July annual redeterminations in July

ｸApril and August annual redeterminations in August

Request For Tax Household Information (RFTHI) Redetermination Packet Counties are hereby instructed to use the RFTHI Redetermination Packet. The RFTHI Redetermination Packet collects the necessary income and tax household information that is missing from their current Medi­Cal case in order to conduct a MAGI eligibility determination.

The beneficiary is not required to physically return the RFTHI Redetermination Packet. The beneficiary can provide the information requested in the packet by mail, by fax, in person, or over the phone.

All County Welfare Directors Letter No.: 14­03

Page 3

February 10, 2014

The RFTHI Redetermination Packet is shown as Attachment A of this letter. This packet consists of the following components:

1.Cover Letter ­ The cover letter explains to a Medi­Cal beneficiary the change to the Medi­Cal annual redetermination process as prescribed in the ACA.

2.Instructions Page ­ The instructions page explains to the beneficiary how to complete the form.

3.RFTHI Form ­ This is the main annual redetermination form. One of these forms must be completed, or the information must otherwise be provided, by each member of the household; however, only the head of household must complete Section 9 and sign the form.

4.RFTHI Supplemental Form – This form supplements the RFTHI form. This form must be completed, or information otherwise provided, once for the entire household. Only one Supplemental Form per household is required.

Please note; the supplemental forms that are currently sent with the Medi­Cal annual redetermination packet continue to be sent with the RFTHI packet. The RFTHI packet is simply replacing the MC 210RV and MC 201PS packet with the RFTHI Redetermination Packet for 2014.

The Department will be issuing further guidance on the 2014 annual redetermination process very shortly.

If you have any questions, please contract Braden Oparowski by phone at (916) 552­9570 or by email at Braden.Oparowski@dhcs.ca.gov.

Original Signed By:

Tara Naisbitt, Chief

Medi­Cal Eligibility Division

You must fill out one of these forms for each person in your household and return it to the

County

Case Number (optional)	SSN or ATIN/ITIN
Individuals’ Name	Birth date (mm/dd/yyyy)
Current street address, apartment number	City	Zip code
Mailing address, if different from above	City	Zip code

1.	Is this person: ☐ Employed	☐ Self-Employed
2.	If this person is currently employed, list all of the information about all types of income received including:

Employer Name: _______________________________________ Employer Address: _______________________

Employer Phone Number: _____________________________ Average Hours Worked Each Week: _________

Wages/Tips (before Taxes): ____________ ☐Hourly ☐ Twice a Month ☐ Semi Monthly ☐Monthly ☐ Yearly

3. If this person is self-employed, answer the following question:

Type of work: ____________________________________

Home much net income (profit once business expenses are paid) will you receive from self-employment this month?:

_________________________________________

4.	For this person, do you plan to file a federal income tax return NEXT YEAR? ☐Yes, complete a-c					☐No, skip to c
a.	Will you file jointly with a spouse?	☐No	☐Yes, Name of Spouse: ___________________________________
b.	Will you claim any dependents?	☐No	☐Yes, Name of Dependents _______________________________
c.	Will you be claimed as a dependent on someone’s tax return? ☐NO			☐Yes
	If yes, list the name of the tax filer:		How is this person related to the tax filer:
5.	Please answer the following questions only if this person is under the age of 21 and a full time student:
Did this person have health insurance through a job and lost it within the last 12 months? ☐Yes					☐No
6.	Were you or anyone else in your family who is age 26 or younger in foster care at the age of 18?					☐Yes ☐No
7.	Has this person’s immigration or citizenship status changed in the past 12 months? ☐ Yes				☐No

If Yes, please explain what changed: __________________________________________________________________

8. Is this person:

☐Hispanic ☐Latino

☐Spanish ☐ American Indian or Alaskan Native ☐ White

☐Black or African American ☐ Filipino ☐ Chinese ☐ Japanese ☐ Cambodian ☐ Korean ☐ Vietnamese

☐Asian Indian ☐Laotian	☐Other Asian, specify: _____________________		☐Native Hawaiian
☐Guamanian or Chamorro	☐Samoan	☐Other or Mixed Race
HCR RFTHI - Request for Additional Information Form			Page 2

9.Renewal of coverage for future years:

To make it easier to determine my eligibility for help applying for health coverage in future years, I agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me make any changes, and I may opt out at any time.

☐5 years (the maximum number of years allowed), or for a shorter number of years:

☐4 years

☐3 years

☐2 years

☐1 year

☐Don’t use information from tax returns to renew my coverage.

**Note: The income/tax filing information is required for all household members. If additional family members are employed or self-employed, questions 1-4 should be answered for these individuals as well.

Your Rights and Responsibilities
ｸ I am signing this renewal form under penalty	ｸ If I think Covered California has made a mistake. I
of perjury. That means that I have provided	can appeal its decision. To appeal means to tell
true answers to all the questions on this form	someone at Cover California that I think the action is
to the best of my knowledge, and I know that	wrong, and ask for a fair review of the action. I know
I may be subject to penalties under federal	that I can find out how to appeal by contacting
law if I provide false or untrue information.	Covered California at 1-800-300-1506. Someone
	from Covered California will explain anything about
ｸ I know that I must tell Covered California if	this application to me if I need that.
anything changes and is different from what I
wrote on this form. I can call 1-800-300-1506	ｸ I understand that if I do not qualify for other kinds of
or visit coveredca.gov to report any changes. I	health coverage. Covered California may send my
understand that a change in my information	information to another program so they can see if I
might affect whether someone in my	qualify.
household qualifies for coverage.
ｸ I know that under federal law, discrimination
is not permitted on the basis of race, color,
national origin, sex, age, sexual orientation,
gender identity, or disability. I can file a
complaint of discrimination by visiting
hhs.bov/ocr/office/file.

I declare, under penalty of perjury, under the laws of the State of California that all information provided on this form is true and correct.

Signature	Date

Need help?	Call Covered California at 1-800-300-1506 (TTY: 888-889-4500). You can
	call Monday through Friday, 8:00 A.M. to 5:00 P.M.
HCR RFTHI - Request for Additional Information Form		Page 3

Is anyone in your household pregnant? ﾅ Yes ﾅ No If yes, who? ________________________

	If yes, what is your expected due date? ________________	How many babies are expected? __________________
	Has anyone moved into or out of the home in the past 12 months?		ﾅYes ﾅNo
	If yes, who __________________________ What is your relationship to this person? ___________________________
	What language should we write you in? ________________			What language do you want us to speak to you in? _______________
	If anyone in your household has changed their citizenship/immigration status in the past 12 months, list the name(s) below:
	Name of Person (Include first and last name)			New Immigration or Citizenship Status

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Examples of income not from a job

Use this list for “Does anyone have income that is not from a job?”

ｸUnemployment benefits

ｸSocial Security benefits

ｸRetirement or pension income

ｸRent or royalty income

ｸAlimony received

ｸInvestment income

ｸCapital gains

ｸFarming or fishing income

ｸCanceled debts

ｸCourt awards

ｸJury duty pay

ｸOther income not from a job

Deductions

Use this list for “Does anyone in the household have deductions?”

ｸCertain self-employment expenses

ｸStudent loan interest deduction

ｸTuition and fees

ｸEducator expenses

ｸIRA contribution

ｸMoving expenses

ｸPenalty on early withdraw of savings

ｸHealth savings account deduction

ｸAlimony paid

ｸDomestic production activities deduction

ｸCertain business expenses of reservists, performing artists, and fee-based government officials

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