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Letter No.:25-01 Page 2 January 21, 2025 Upon request from the Medi-Cal member, the Medi-Cal member’s parent or legal guardian, or the Medi-Cal member’s authorized representative, counties shall retroactively change eligibility for the following circumstances: • Advance Premium Tax Credit (APTC) individuals o APTC eligible individuals, who are redetermined eligible for Medi-Cal using the 2025 FPL figures, may be eligible for retroactive Medi-Cal. The county shall only retroactively change eligibility for APTC individuals who did not enroll in a Qualified Health Plan (QHP), did not pay a premium, or who did enroll in a QHP and pay a premium, but have Medi-Cal covered medical or dental expenses that were not covered by their QHP during the retroactive period. o APTC eligible individuals, described above, may be eligible for retroactive Medi-Cal out-of-pocket expense reimbursements (Conlan). Please see MEDIL I 07-02 for additional information about the Conlan process. Note: The Centers for Medicare and Medicaid Services has decided that there will be no reimbursement for premiums paid to Covered California QHPs. The notice sent by DHCS will state that no Covered California QHP premium reimbursements will be available. Please see ACWDL 16-08 for instructions on determining retroactive Medi-Cal coverage when an individual is transitioning from Covered California coverage. • Individuals with a Share-of-Cost (SOC) o Individuals who are redetermined eligible with zero SOC or with a resulting lower SOC Medi-Cal, when using the 2025 FPLs, who had out of pocket expenses for covered medical or dental services, may be eligible for retroactive expense reimbursements (Conlan). o Please reference the DHCS website and MEDIL I 07-02 for additional information about the Conlan process. Please note: DHCS is coordinating implementation of the 2025 FPLs in the California Healthcare Eligibility Enrollment and Retention System (CalHEERS) and California Statewide Automated Welfare System (CalSAWS). DHCS anticipates the CalHEERS system and CalSAWS system will be updated with the annual 2025 FPL amounts during the month of February of 2025.