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Eligibility for Individuals and Families

Participant Guide

Version 3.0

Covered California Participant Guide Course Name: Eligibility for Individuals and Families Version 3.0

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TABLE CONTENTS

1 Course Objectives ................................................................................................... 1

2 Overview of the Application and Enrollment Process .......................................... 1

HOW TO APPLY FOR COVERAGE ................................................................................................... 1

APPLICATION SECTIONS AND QUESTIONS ..................................................................................... 2

APPLICATION PROCESSING TIMES ................................................................................................ 4

RESOLVING INCONSISTENCIES ...................................................................................................... 4

ENROLLMENT PERIODS ................................................................................................................ 6

SPECIAL ENROLLMENT AND QUALIFYING EVENTS ......................................................................... 7

3 Determining Eligibility Based on Household Income and Size .......................... 11

HOUSEHOLD INCOME AND FEDERAL POVERTY LEVEL ...................................................................11

ELIGIBILITY AND MODIFIED ADJUSTED GROSS INCOME .................................................................11

CALCULATING MAGI ..................................................................................................................12

VERIFYING HOUSEHOLD SIZE AND INCOME ...................................................................................13

PROJECTING SELF-EMPLOYMENT INCOME FOR MAGI ...................................................................13

MIXED PROGRAM FAMILIES .........................................................................................................13

4 Covered California Eligibility Requirements ....................................................... 16

WHO CAN APPLY FOR COVERAGE? .............................................................................................16

UNDERSTANDING LAWFUL PRESENCE, IMMIGRATION STATUS, DOCUMENTATION AND ELIGIBILITY ..16

VERIFYING RESIDENCY, INCARCERATION, CITIZENSHIP AND IMMIGRATION STATUS FOR COVERED CALIFORNIA HEALTH PLANS .......................................................................................................20

5 Medi-Cal Health Coverage and Eligibility ............................................................ 20

MEDI-CAL ELIGIBILITY OVERVIEW ...............................................................................................20

EXPANDED MEDI-CAL GROUP .....................................................................................................21

OTHER MEDI-CAL GROUP ...........................................................................................................21

FORMER FOSTER CARE CHILDREN’S PROGRAM ...........................................................................22

CITIZENSHIP AND IMMIGRATION STATUS FOR MEDI-CAL ELIGIBILITY ..............................................22

CALIFORNIA MEDI-CAL RESIDENCE REQUIREMENTS ....................................................................24

NO FIVE-YEAR WAITING PERIOD IN CALIFORNIA FOR LAWFULLY PRESENT INDIVIDUALS ................24

MEDI-CAL ELIGIBILITY DETERMINATION FOR HOUSEHOLD INCOME AND SIZE .................................24

ELIGIBILITY DETERMINATION PROCESS ........................................................................................25

ENROLLMENT PERIOD AND APPLICATION PROCESSING TIMES ......................................................26

PRESUMPTIVE ELIGIBILITY PROGRAMS ........................................................................................26

MEDI-CAL ESTATE RECOVERY PROGRAM ....................................................................................27

CHILD HEALTH AND DISABILITY PREVENTION PROGRAM ...............................................................28

CONCERNS OR COMPLAINTS .......................................................................................................29


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6 Eligibility and Enrollment for American Indians and Alaska Natives ................ 29

ELIGIBILITY FOR THE ELIMINATION OF COST-SHARING EXPENSES .................................................30

EXEMPTION FROM INDIVIDUAL MANDATE PENALTIES ....................................................................31

ENROLLMENT PERIODS ...............................................................................................................31

VERIFICATION OF STATUS ...........................................................................................................31

7 Processes for Referrals, Appeals and Complaints ............................................. 31

REFERRALS TO NON-COVERED CALIFORNIA HEALTH PROGRAMS .................................................31

CONSUMER APPEALS PROCESS ..................................................................................................32

SUPPORT FOR CONSUMERS WITH CONCERNS OR COMPLAINTS .....................................................32

8 Endnotes ................................................................................................................ 34


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1 COURSE OBJECTIVES

Explain how and when the consumer can apply for coverage

Explain enrollment periods and qualifying life events

Describe the eligibility requirements for Covered California health plans and Medi-Cal

Understand how to determine tax household income and size

Describe eligibility, verification and the enrollment process for American Indians and Alaska Natives

Describe the appeals process for consumers

2 OVERVIEW OF THE APPLICATION AND ENROLLMENT PROCESS

HOW TO APPLY FOR COVERAGE

The first step in obtaining coverage begins with the consumer completing the Covered California enrollment application. Consumers can apply in the way that works best for them, including:

Online at: www.CoveredCA.com

In-person with an individual certified by Covered California to perform enrollment assistance

In-person with an eligibility worker at a county social service office

By contacting the Covered California Service Center at (800) 300-1506

By US Postal mail or by fax (this is not the preferred application method as it may result in a delayed eligibility determination)

The Covered California enrollment application asks questions that are necessary for determining eligibility, including:

Number of household members: members who need health insurance, and their place of residence

Income of tax household members: includes salaries, wages, and unearned income

Citizenship/immigration status of those applying for coverage

Social Security Numbers (SSN), or Individual Taxpayer Identification Numbers (ITIN), which are used to verify income and immigration/residence status. SSNs will not be necessary for individuals who do not require health insurance, but are helpful in verifying information for those applying for coverage. For example, a mother who is not seeking coverage for herself and is applying for one of her children only needs to provide the child’s SSN, if available

Rights and Responsibilities page: must be signed by the consumer (or their authorized representative). This page cannot be signed by the consumer’s Certified Enrollment Counselor or other certified in-person assister. By signing this page, the consumer acknowledges that they:

o Have provided true and accurate information

o Understand their rights as consumer

o Agree to other responsibilities, such as annual redetermination and reporting income changes

http://www.coveredca.com/


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Consumers will be determined eligible for one of three paths to health coverage through Covered California:

1. A Covered California health plan at full price (without financial assistance)

2. A Covered California health plan with financial assistance

3. Referred to Medi-Cal

APPLICATION SECTIONS AND QUESTIONS

Understanding the application sections and the information required are key to submitting a complete and successful application. The application is a dynamic process and may create additional fields depending on the information submitted by the consumer.

Important – Disclosure of Immigration Status

All information provided about immigration status for determining eligibility for health coverage through Covered California will be kept secure and private. Under NO circumstances will this information be used by an immigration agency for the purpose of enforcement.

The following is an overview of the sections of the application:

Application Section Questions (General Summary)

Getting Started Whether or not the consumer is applying for financial assistance

Whether the consumer is getting assistance in filling out the application (i.e. from a Certified Enrollment Counselor)

Whether the consumer is applying during the special-enrollment period

General questions regarding household size

How the consumer learned about Covered California

Consent to the information verification process performed by Covered California

Primary Contact Information

This information includes:

Name

Telephone number

Home mailing address

Email address

Identity Verification Process (Remote Identity Proofing)

Preferences for:

Method of communication

Written and spoken language

Additional Household Members

Information about individuals living in the home and whether they are applying for coverage (tax dependents are considered household members whether or not they live in the home)

Name


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Date of birth

Gender

US citizen, national or lawfully present status if applying for coverage through Covered California

Social Security Number or Alien Number

Relationship of household members to each other

Contact information if different from that of the primary contact

Applicant and Household Member Demographic Data

Marital status

Pregnancy status and, if pregnant, due date and number of children expected

Member of a federally recognized American Indian/Alaska Native

Full-time student

Blind or disabled, or both (for non-MAGI Medi-Cal eligibility determination)

Medical expenses in the last three months (relevant if consumer requests retroactive Medi-Cal coverage)

Pending medical bills within the last three months

In foster care at the age of 18 (for Medi-Cal eligibility consideration)

Applicant’s Additional Household Member(s) Tax Information

Tax filing status:

Number of dependents claimed

Head of household status

Agrees to file a tax return(s) for the current benefit year

Whether or not the consumer filed taxes in the previous benefit year

Applying Family Members’ Health Care Information

Whether they have employer-sponsored health insurance coverage that meets the minimum standard value and affordability tests

Long-term care needs (for non-MAGI Medi-Cal eligibility determination)

Medicare coverage status

Applying Family Members’ Request for Referral to Non-Health Care Service Programs

CalWORKS Program

CalFresh Program

Optional Information Ethnicity

Race

Languages spoken / written

Income Information Income type

Income source


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Income amount

Frequency of payment

Income Summary Review of consumer’s current and projected annual income (for the current benefit year)

Signature Page Consumer’s rights and responsibilities

Consumer’s signature

APPLICATION PROCESSING TIMES

Covered California’s goal is to provide consumers with health insurance as quickly and easily as possible. Application processing times vary according to:

The manner in which the application is submitted

Whether or not the application is complete and has consistent information

Whether the application requires further verification

The table below provides additional information on the processing time, based on application submission method:

Application Submission Method Time Frame

Online

Certified In-Person Counselor or Agent

By telephone

Processing will take more time if additional information is required or if inconsistent information is provided

Processed in real time. This applies to applications that do not require resolution of any inconsistent information

Paper applications that are received by conventional mail or fax

Within 10 calendar days

Missing or inconsistent information may cause a processing delay

Applying the Reasonably Compatible Standard to Consumer Information

Covered California applies a reasonably compatible standard to any differences or discrepancies between the application information and the verification data sources. In other words, slight differences will not impact a consumer’s eligibility. However, if the consumer’s attestation is not reasonably compatible with available information or data, then Covered California will follow a process to resolve inconsistencies.

RESOLVING INCONSISTENCIES

Consumers have 90 days to resolve an inconsistency between eligibility information they provided on the application versus what was determined by the federal data sources.

NOTE: If an application requires resolution of an inconsistency based on income, the consumer may be conditionally eligible for a Covered California health plan and use any premium assistance and cost-sharing reductions if their attested information qualifies them. It is


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important to know that if it turns out they are not eligible they must pay back any premium assistance amount received, up to a certain dollar amount.

A process is in place to resolve inconsistencies identified when information from the consumer is not reasonably compatible with Covered California data sources.

The steps are as follows:

Step 1: Covered California first tries to address the cause of the inconsistency between the data sources and the consumer’s attestation by requesting a reasonable explanation from the consumer. If the consumer provides a reasonable explanation for the discrepancy, eligibility is determined based on the information the consumer provides.

Example

A consumer may have recently lost their job and currently has no income. This may be considered a reasonable explanation for why the current data sources indicate the individual’s earnings are above Medi-Cal eligibility levels.

If the consumer is unable to provide a reasonable explanation, Step 2 is followed.

Step 2: Covered California notifies the consumer about the inconsistency and requests acceptable verification documents.

Documentation must be submitted within 90 days of submitting the application. Consumers can upload the document(s) on their online Covered California account (preferred) or send a copy via fax at 888.329.3700 or mail it to:

Covered California P.O. Box 989725 West Sacramento, CA 95798-9725

Examples

If an individual attests to their income and Covered California was unable to verify the attestation against current data sources, the individual may be required to provide their most recent pay stubs;

OR

If an individual attests to being a lawful permanent resident, but Covered California is unable to verify this status with the Department of Homeland Security, the consumer may have to provide a copy of their Green Card (or other lawfully present documentation).

During the 90-day resolution period, Covered California proceeds with all other elements of eligibility determination and may provide temporary coverage with financial assistance, which includes making sure that any advance payments for premium assistance and cost-sharing reductions are applied. Consumers are required to attest that they understand that any payments made on their behalf must be reconciled when they file their tax return for the benefit year.

Step 3: If, after Step 2, Covered California still is unable to verify the consumer’s information, eligibility for financial assistance will be decided based on the information from the databases used to verify the information reported by the consumer. In the case of Medi-Cal eligibility, certain information that cannot be verified will halt the eligibility process, and the consumer’s county social services office will follow up directly with the individual.


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NOTE: Covered California is required to make a determination between 10 and 30 days after the date it sent the notice to the consumer that there was an inconsistency.

Requesting an Extension

Consumers who need more time to address inconsistencies can request an extension by using the following procedure:

Step 1: The consumer should contact the Covered California Service Center at (800) 300-1506 to explain why they need an extension.

Step 2: Covered California will review the request and send a decision to the consumer. If Covered California approves the extension, they will follow up with the consumer by phone or written notice within 30 days from the date of extension approval.

Example

An extension may be granted if a consumer demonstrates that they are making every effort to obtain documentation to resolve an inconsistency. For instance, the consumer provides Covered California with a photocopy of a letter or email message sent to an agency requesting the necessary documentation.

Step 3: The consumer has 30 days from the date of the Covered California notice of approval for an extension to respond. If the consumer responds to the notice explains why they still cannot provide the documents, Covered California will determine if they continue to qualify for the extension and will send written notification about the decision to the consumer.

Case-by-Case Exceptions

On a case-by-case basis, Covered California may accept a consumer’s explanation of the information which cannot be verified and the circumstances preventing them from obtaining documentation if:

The documentation required to resolve the inconsistency does not exist or is not reasonably available

The inconsistency is not related to citizenship or immigration status

Covered California has no other way to resolve the inconsistency for the consumer

As a last resort, the consumer can sign an attestation statement under penalty of perjury for the information in question.

ENROLLMENT PERIODS

Open-Enrollment Period

Consumers who are eligible for a Covered California health plan, with or without financial assistance, can apply for coverage during the annual open-enrollment period. Note: There are no enrollment periods for Medi-Cal coverage. Consumers eligible for Medi-Cal may enroll at any time throughout the year. The initial open enrollment for period was October 1, 2013 through March 31, 2014.

2015 Open Enrollment starts November 15, 2014 and runs through February 15, 2015.

For subsequent years, the open-enrollment period will run from Oct. 15 to Dec. 7.


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Key enrollment, premium payment and coverage effective dates Covered California health plans:

Enrollment Date Premium Due Date Coverage Effective Date

Between the 1st and 15th of the month

Four business days before the end of each month

The first day of the following month

Example: Coverage for a consumer who enrolls and pays the premium on March 10, 2014, will be effective April 1, 2014.

Between the 16th and last day of the month

Four business days before the end of the following month

The first day of the second following month

Example: Coverage for a consumer who enrolls and pays the premium on March 17 will be effective May 1.

*Note: during open-enrollment 2015, coverage for consumers who enroll prior to December 15, 2014 will not be effective until January 1, 2015.

SPECIAL ENROLLMENT AND QUALIFYING EVENTS

Special enrollment is a time outside of the open-enrollment period during which consumers, with certain circumstances known as qualifying events, can sign up for health care coverage. Consumers can begin the special-enrollment process by going to CoveredCA.com or by contacting the Covered California Service Center at 800-300-1506 or a certified in-person counselor or agent.

Qualifying Events

For Covered California’s special-enrollment qualifying events should be reported within 60 days of the date of the event. If consumers do not meet one of these qualifying events, they must wait until the next year to enroll in coverage. When consumers apply for coverage, they will need to select a qualifying life event from a drop-down menu and will be asked the date of the event. The chart below will help you answer those questions.

QUALIFYING LIFE EVENT DESCRIPTION

DATE TO ENTER ON COVEREDCA.COM

COVERAGE EFFECTIVE DATE

LOSS OF HEALTH INSURANCE

Loss of Medi-Cal coverage.

Loss of employer-sponsored

coverage.

COBRA coverage is

exhausted. (Failure to pay

COBRA premium is not

considered loss of coverage.)

Enter the date of the loss of coverage

The first day of the month following the plan selection. (Regardless of when the event and the plan selection happened throughout the month). For retroactive coverage, contact the Covered California Service Center (800) 300-1506


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No longer eligible for student

health coverage.

Consumer turns 26 years old

and are no longer eligible for

a family plan.

Consumer turns 19 years old

and are no longer eligible for

a child-only plan.

PERMANENTLY MOVED TO/WITHIN CALIFORNIA

Consumer moves to

California from out of state.

Consumer moves within

California and gain access to

at least one new Covered

California health plan.

Enter the date of the permanent move

If a plan is selected by the 15th, coverage starts on the following 1st of the following month. If a plan is selected after the 15th, coverage starts on the 1st of the second following month

HAD A BABY OR ADOPTED A CHILD

A child is born, adopted or

received into foster care.

The consumer’s child is

placed for adoption or foster

care.

Enter the date of birth, adoption or foster placement

Day of Event (retroactive coverage effective date). For retroactive coverage contact the Covered California Service Center (800) 300-1506

GOT MARRIED OR ENTERED INTO A DOMESTIC PARTNERSHIP

Two consumers, get married

or enter into a domestic

partnership. Both can apply.

A consumer who has no

coverage marries or enters a

domestic partnership with a

consumer who has a Covered

California health plan. Both

can apply or renew their

coverage.

Enter the date on the marriage or domestic partnership license

The first day of the month following the plan selection. (Regardless of when the event and the plan selection happened throughout the month). For retroactive coverage contact the Consumer Service Center (800) 300-1506

RETURNED FROM ACTIVE DUTY MILITARY SERVICE

Loss of coverage after leaving active duty, reserve duty, or the California National Guard.

Enter the date the consumer returned from active duty.

If a plan is selected by the 15th, coverage starts on the 1st of the following month. If a plan is selected after the 15th, coverage


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starts on the 1st of the second following month.

RELEASED FROM INCARCERATION

Consumer is released from jail or prison.

Enter the date you apply for Covered California.

If a plan is selected by the 15th, coverage starts on the 1st of the following month. If a plan is selected after the 15th, coverage starts on the 1st of the second following month.

GAINED CITIZENSHIP/LAWFUL PRESENCE

Consumer becomes a citizen, national, or permanent legal resident.

Enter the date on the immigration document.


AMERICAN INDIAN/ALASKAN NATIVE

Consumer is a member of a federally recognized American Indian tribe. Consumer may apply at any time.



OTHER QUALIFYING LIFE EVENT

Consumer enrolled in a

Covered California health

plan and become newly

eligible or ineligible for tax

credits or cost-sharing

reductions.

Misconduct or

misinformation occurred

during the enrollment

Misrepresentation or

erroneous enrollment

Exceptional circumstances

occurred on or around plan

selection deadlines,


If a plan is selected by the 15th, coverage starts on the 1st of the following month. If a plan is selected after the 15th, coverage starts on the 1st of the second following month. Covered California may grant earlier effective date based on the specific circumstances of each case.


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including natural disasters

and medical emergencies.

Consumer received a

certificate of exemption for

hardship from Health and

Human Services for a

month or months during the

coverage year but lost

eligibility for the hardship

exemption outside of an

open-enrollment period.

Consumer started or ended

membership of

AmeriCorps/VISTA/

National Civilian Community

Corps outside of an open-

enrollment period

Consumer has a

grandfathered health

insurance plan

Consumer’s provider left the

health plan network while

receiving care for a serious

condition

NONE OF THE ABOVE

If none of these qualifying life events are applicable, the consumer should still apply for coverage using "None of the above," because they may be eligible for Medi-Cal or the Medi-Cal Access program for pregnant women based on income. Regardless of which life event is selected, the consumer’s application will still be reviewed for eligibility in Medi-Cal or the Medi-Cal Access Program.



The table below describes the health coverage effective date based on the date of the qualifying event:


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Date of Qualifying Event Coverage Effective Date

Event occurring on the 1st through the 15th of the month

First day of the following month

Event occurring on the 16th through the last day of the month

First day of the second following month

Birth, adoption, or placement for adoption Date of birth, adoption, or placement for adoption. Note: any financial assistance will be effective the first day of the following month of birth.

Marriage/Domestic Partnership First day of the following month following plan selection

3 DETERMINING ELIGIBILITY BASED ON HOUSEHOLD INCOME AND SIZE

HOUSEHOLD INCOME AND FEDERAL POVERTY LEVEL

To determine eligibility options for consumers, the tax household income is compared with the federal poverty level (FPL) guidelines for the household size. FPL is based on the minimum amount of gross income (before taxes) that a household needs for food, clothing, transportation, shelter, and other necessities. The US Department of Health and Human Services (HHS) determines the FPL each year, which varies by family size and is adjusted for inflation. Medi-Cal implements the new FPL guidelines on April first. Covered California, however, continues to use the previous year’s FPL guidelines until the next open-enrollment period. During special enrollment, the CoveredCA.com application factors in both the old and new FPL guidelines for applications submitted prior to the start of the next open-enrollment period. For example, during special enrollment in 2014, Covered California used the 2013 FPL thresholds and Medi-Cal used the 2014 FPL thresholds. Covered California will use the 2014 FPLs for open enrollment, which begins November 15, 2014 for coverage that starts January 1, 2015.

ELIGIBILITY AND MODIFIED ADJUSTED GROSS INCOME

A tax household’s modified adjusted gross income (MAGI) is used to determine eligibility for subsidized health insurance through Covered California and for income-based Medi-Cal.

For most consumers, their adjusted gross income (AGI) is the same amount as their MAGI. Consumers can find their AGI on the following federal tax return lines:

Line 4, Form 1040EZ

Line 21, Form 1040A

Line 37, Form 1040

IMPORTANT TO NOTE: Taxpayers who receive non-taxable Social Security benefits, earn income living abroad or earn non-exempt interest should add that income to their AGI to calculate their MAGI. It is important to remind a consumer that if they claim a spouse or children as dependents, their income counts towards the tax household income. In order to receive financial assistance through Covered California, spouses are required to file their income tax return jointly.

To perform MAGI calculations, Covered California requires consumers to provide the following:

An attestation to their current or projected income for the current benefit year.


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If the consumer’s income varies from month to month, income should be based on a monthly average of expected earnings for the current benefit year (projected average annual income). To make this income estimate, consumers need to take the following factors into consideration:

o Their income pattern over the last year

o The actual income they received in the last month

o The ability to provide a statement of anticipated income, which can be presented as a self-affidavit letter of income

If a consumer’s attested income is not reasonably consistent with available federal data, or if income information is not available, the consumer has 90 days to provide Covered California with documentation to resolve the inconsistency (i.e., by presenting current paystubs or the previous year’s tax return).

CALCULATING MAGI

It is important to understand all sources of income that will be counted in MAGI as certain types of income may be deducted or not included when calculating MAGI. The following table describes sources of income as they relate to MAGI.

What is included in MAGI? What is deducted from MAGI? What is not included in MAGI?

Wages, salaries, self-employment income, tips, and commissions

Certain allowable self-employment expenses

Foster Care payments

Taxable interest and ordinary dividends

Student loan interest deduction

Veterans’ disability payments

Taxable amount of a pension, annuity, or IRA distribution

Educator expenses Workers’ compensation payments

Social Security benefits IRA deduction

Child support received

Business income Moving expenses

Supplemental Security Income (SSI)

Farm income Penalty on early withdrawal of savings

Also not included in MAGI because these items are already subtracted from W-2 wages and salaries are pre-tax contributions for:

Child care

Commuting

Employer-sponsored health insurance

Capital gains and other gains (or losses)

Health savings account deduction

Unemployment compensation

Alimony paid

Alimony received Certain business expenses of reservists, performing


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What is included in MAGI? What is deducted from MAGI? What is not included in MAGI?

Income from rental real estate, royalties, and partnerships

artists, and fee-basis government officials

Flexible spending accounts

Retirement plans such as a 401(k) or 403(b)

Taxable refunds, credits, or offsets of state and local income taxes

Other taxable income

VERIFYING HOUSEHOLD SIZE AND INCOME

Covered California verifies household size and MAGI income using both tax return and state data sources.

To verify the consumer’s attestation of income, Covered California obtains IRS tax return data from the Secretary of the Treasury via the federal hub. When verifying a consumer’s attestation of income for determining Medi-Cal eligibility, Covered California uses a combination of both IRS data and current data sources. If IRS data is not available, or the consumer’s attestation is not reasonably compatible with the IRS data, Covered California will rely on current data sources.

PROJECTING SELF-EMPLOYMENT INCOME FOR MAGI

If an individual has worked less than a year, or not long enough to file a tax return in the previous year, a projection of annual self-employment income can be made by:

1. Adding together gross self-employment income and any profit made from selling business property or equipment during the time the business has been in operation within the last year.

2. Subtracting business expenses allowed by the IRS.

One way to project self-employment income for the current benefit year is by using the income and deductions claimed on the previous year’s taxes (Form 1040, Line 12 of Schedule C), if an individual worked long enough to file a federal tax return for the previous year, and it is representative of their current income.

MIXED PROGRAM FAMILIES

Members of the same family or household may be eligible for different types of health coverage. Families in this situation are referred to as mixed program families. For example, a family’s application could show that one parent who has affordable coverage through their job qualifies to purchase a Covered California health plan with no financial assistance, while the other parent may qualify for financial assistance through a Covered California health plan, while the children could qualify for Medi-Cal.

The following table shows the available health coverage options available through Covered California and the corresponding household size and income guidelines for 2015:


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Program Eligibility by Federal Poverty Level

Household Size

Premium Assistance

(PA) Eligible under

5-year bar

Eligible for Premium Assistance (PA)

Eligible for Medi-Cal (MAGI) Enhanced Silver Plan

Medi-Cal Kids Eligible (no PA)

Expanded

Medi-Cal (up

to 138%)

formerly Healthy Families

(up to 266%) The Medi-Cal Access Program* (213%-322%)

< 100% 100% 133% 138% 150% 200% 250% 300% 400%

1 $0- $11,669 $11,670 $15,521 $16,105 $17,505 $23,340 $29,175 $35,010 $46,680

2 $0 - $15,729 $15,730 $20,921 $21,707 $23,595 $31,460 $39,325 $47,190 $62,920

3 $0 - $19,789 $19,790 $26,321 $27,310 $29,685 $39,580 $49,475 $59,370 $79,160

4 $0 - $23,849 $23,850 $31,721 $32,913 $35,775 $47,700 $59,625 $71,550 $95,400

5 $0 - $27,909 $27,910 $37,120 $38,516 $41,685 $55,820 $69,775 $83,730 $111,640

6 $0 - $31,979 $31,980 $42,520 $44,119 $47,995 $63,940 $79,925 $95,910 $127,880

7 $0 - $36,029 $36,030 $47,920 $49,721 $54,045 $72,060 $90,075 $108,090 $144,120

8 $0 - $40,089 $40,090 $53,320 $55,324 $60,135 $80,180 $100,225 $120,270 $160,360

For each additional

person, add $4,060 $5,400 $5,603 $6,090 $8,120 $10,150 $12,180 $16,240

Effective 4/1/2014-3/31/2015


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4 COVERED CALIFORNIA ELIGIBILITY REQUIREMENTS

WHO CAN APPLY FOR COVERAGE?

Any California resident can apply for health insurance coverage through Covered California regardless of their tax household income or whether they currently have health coverage. To be eligible to apply, a consumer must be:

A California resident (or a person who intends to reside in California). Consumers are required to provide their address on the online application as part of the eligibility verification process

A US citizen, US national, or lawfully present in the US

Not incarcerated

Immigrants who are not considered lawfully present are not eligible to purchase a Covered California health plan. However, they can still apply through Covered California to pre-screen for health coverage options through Medi-Cal, but the benefits may be limited.

Incarceration Status and Eligibility

Consumers are not eligible for a Covered California health plan if they are incarcerated post-disposition (i.e., convicted of a crime and serving a sentence). However, individuals awaiting the disposition of their charges are eligible. For example, a person who was arrested and is awaiting trial is eligible to enroll in a Covered California health plan or Medi-Cal.

UNDERSTANDING LAWFUL PRESENCE, IMMIGRATION STATUS, DOCUMENTATION AND ELIGIBILITY

US citizens, US nationals and individuals considered lawfully present have access to affordable, quality coverage through Covered California. Depending on income, they may be eligible for Covered California health plans with financial assistance or for low- or no-cost coverage through Medi-Cal. California residents who are not considered lawfully present are exempt from the requirement to have health insurance and can file for an exemption directly with the IRS. They can also use Covered California to see if they are eligible for limited or reduced-scope health coverage options through Medi-Cal.

The following tables include, but are not limited to, the most common definitions of US citizens, US nationals and lawfully present individuals. The tables also describes the valid documentation required to determine program eligibility.

Status Definition Valid Documentation Program Eligibility

US Citizen or US National

Born in the US or a person who owes permanent allegiance to the US (i.e. those born in American Samoa or Swains Island)

Social Security Number Covered California health plan, with or without financial assistance

Full-scope Medi-Cal

US Naturalized Citizen


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Person has been naturalized as a US citizen (became a US citizen after birth)

Certificate of Naturalization (N-550 or N-570)

Certificate of US Citizenship (N-560 or N-561)

Covered California Health Plan, with or without financial assistance

Full-scope Medi-Cal


Lawfully Present Individuals

Qualified non-citizens/immigrants:

o Lawful permanent residents (LPR/Green Card Holders)

o Asylees

o Refugees

o Cuban/Haitian entrants

o Individuals paroled into the US for at least one year

o Individuals with conditional entry granted before 1980

o Battered non-citizens, spouses, children, or parents

o Victims of trafficking along with their spouses, children, siblings, or parents, or individuals with a pending application for a victim of trafficking visa

o Individuals granted withholding of deportation

o Members of federally recognized Indian tribes or American Indians born in Canada

Depending on individual’s situation:

Green card number (Resident Alien Number) with expiration date (I-551)

Reentry Permit (I-327)

Refugee Travel Document (I-571)

Employment Authorization Card (I-766)

Machine Readable Immigrant Visa (with temporary I-551 language)

Temporary I-551 Stamp (on passport or I-94/I-94A)

Arrival/Departure Record (I-94/I-94A)

Arrival/Departure Record in foreign passport (I-94)

Foreign Passport

Certificate of Eligibility for Nonimmigrant Student Status (I-20)

Certificate of Eligibility for Exchange Visitor Status (DS2019)

Notice of Action (I-797)

Covered California health plan, with or without financial assistance

Full-scope Medi-Cal for:

o Individuals up to 21 years of age

o Pregnant individuals with income up to 60% of the federal poverty level (FPL)

o Children in families with income up to 266% of the FPL

o Parents, seniors, and persons with disabilities

o Parents and caretakers with income up to 138% of the FPL

o Adults without children, ages 19 to 64, with income up to 138% of the FPL

Pregnancy-only Medi-Cal for:

o Qualified immigrants who are pregnant with income of 60%-213% of the FPL


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Humanitarian statuses or circumstances (including Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking)

Valid non-immigrant visas

Legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals)

Individual with a work or student visa who intends to become a permanent resident of California

Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada

Certification from US Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)

Office of Refugee Resettlement (ORR) eligibility letter (if under the age of 18)

Document indicating withholding of removal

Administrative order staying removal issued by the Department of Homeland Security

Alien number (also called alien registration number or USCIS number) or 1-94 number

The following table lists the status definition, required documentation and program eligibility for those individuals who are temporary residents:


Temporary residents (who do not intend to reside in California)

Foreign visitors

Students with temporary visas

Individuals with temporary visas

Employment Authorization Card (I-766)

Temporary I-551 Stamp (on passport, I-94, or I-94A)

Arrival/Departure Record (I-94, I-94A) issued by USCIS

Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)

Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019)

Covered California health plan, with or without financial assistance. Must reside in California for, and file taxes in, the benefit year.

Restricted-scope Medi-Cal

Note: The preceding list is not exhaustive, but it does provide the most common immigration statuses for lawful presence.


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No Five-Year Waiting Period for Lawfully Present Individuals

Unlike the federal requirements for Medicaid, there is no required five-year waiting period in California for lawfully present individuals to be eligible for Medi-Cal. For example, under current Medi-Cal policy, eligible green card holders can receive full-scope Medi-Cal coverage in California even if they have been in the US for less than five years. California uses state funds to provide these benefits during the “five-year period” versus federal funds.

Helpful Resources

For more information on the legal requirements for lawful presence, including the definition of qualified immigrants, go to:

http://www.law.cornell.edu/cfr/text/45/152.2

http://www.law.cornell.edu/uscode/text/8/1641

Another helpful resource is the following report: “Lawfully Present Individuals Eligible under the Affordable Care Act,” published by the National Immigration Law Center (September 2012): www.nilc.org/document.html?id=809.

Requirement to Buy Health Coverage

US citizens, US nationals, or lawfully present individuals need to enroll in health coverage by the end of open enrollment. If they do not have health coverage by this date, and do not qualify for an exemption from the Department of Health and Human Services, they must pay a tax penalty when they file taxes in April of that tax year. Individuals who are not lawfully present are exempt from the requirement to have health insurance and will file for their exemption directly with the IRS.

Mixed Immigration Status Families’ Options for Care and Coverage

Many immigrant families are of mixed status, with members having different immigration and citizenship statuses. The concept of mixed status if often confused with mixed program families which refers to households with members that qualify for both Covered California and Medi-Cal. Mixed status families however, only refers to households with individuals who have different immigration statuses. Both lawfully present individuals and individuals not considered lawfully present can apply through Covered California because they may be eligible for health coverage options through Medi-Cal. Individuals not considered lawfully present may also apply for coverage for their lawfully present family members (such as a dependent, US citizen child) who may be eligible for coverage through a Covered California health plan or low or no-cost coverage through Medi-Cal. Only the immigration status of the person who is seeking the health coverage (in this case, the dependent US citizen child) would be needed. For questions about the Covered California health plans available, mixed-program families can call the Covered California Service Center at (800) 300-1506. Covered California will be able to answer questions about its own plans and can transfer those with questions about Medi-Cal plans to the appropriate resource. Consumers can also call Medi-Cal Health Care Options staff directly at 800-430-4263 for questions about Medi-Cal plans.

http://www.law.cornell.edu/cfr/text/45/152.2http://www.law.cornell.edu/uscode/text/8/1641file://192.168.30.10/SHARED/HBEX/Training/Curriculum/Assisters_7.19.13/Consumer%20Eligibility_from%20Manatt/www.nilc.org/document.html%3fid=809.


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VERIFYING RESIDENCY, INCARCERATION, CITIZENSHIP AND IMMIGRATION STATUS FOR COVERED CALIFORNIA HEALTH PLANS

Only individuals planning to enroll in a health plan through Covered California who have stated they are a citizen, national, or lawfully present will be asked for verification information regarding their citizenship or immigration status (such as a Social Security Number or Alien Number).

Undocumented individuals who are not eligible themselves for coverage through a Covered California health plan may apply for family members who are eligible. Non-consumers should not be asked for their citizenship or immigration status when applying for a family member. Undocumented individuals may also apply for an eligibility determination for themselves through Covered California as they may be eligible for Medi-Cal, as described in the next section.

Covered California verifies a consumer’s attestation of citizenship using available data from the Social Security Administration and the Department of Homeland Security. The following table lists the sources used to verify various consumer information. These sources make up Covered California’s federal hub.

Eligibility Factor Data Source Used to Verify Eligibility or Consumer’s Attestation

Social Security Number Social Security Administration

Citizenship Social Security Administration

Department of Homeland Security

Immigration Status Department of Homeland Security

Residency Consumer attestation is accepted unless the information does not match other information available to Covered California

Incarceration Status Attestation is accepted as provided in the application unless the information does not match other information available to Covered California

Income Department of Treasury

Current data sources (i.e. IRS)

Minimum Essential Coverage (MEC)

Department of Health and Human Services (Federal)

Department of Health Care Services (State)

5 MEDI-CAL HEALTH COVERAGE AND ELIGIBILITY

MEDI-CAL ELIGIBILITY OVERVIEW

Medi-Cal offers low or no-cost health coverage for California residents who meet eligibility requirements. It is California’s Medicaid program, financed with both federal and state funding, governed by the Department of Health Care Service (DHCS), and each county in California is responsible for operation of the program at the local level. Medi-Cal is comprised of different sub-programs that specifically target populations in California that are in need of health care services.

Effective January 1, 2014, California expanded Medi-Cal eligibility for some low-income adults. When a consumer completes the Covered California application they will be automatically


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reviewed for Medi-Cal eligibility. Like Covered California, Medi-Cal will use MAGI to determine program eligibility.

As part of the Medi-Cal expansion, the Targeted Low-Income Children’s Program (TLICP) replaced what was known as the Healthy Families Program. TLICP is a low-cost insurance program for children and teens that provide health, dental, and vision coverage to children who do not have health insurance.

Individuals seeking Medi-Cal coverage fall into one of two major groups:

EXPANDED MEDI-CAL GROUP

Expanded Medi-Cal refers to Medi-Cal programs that follow MAGI rules for determining income eligibility and is also referred to as MAGI Medi-Cal. An asset test is not required for this new coverage group. The following table outlines income eligibilities for Expanded Medi-Cal groups:

MAGI Group Description Income Limit

Childless adults Between the ages of 19 and 64

Up to 138% of FPL

Parents and caretaker relatives

Parents and caretaker relatives of a dependent child

Up to 138% of FPL

Children Infants and children under age 19 (or 21 if a full-time student)

Infants (< 2 years old): Up to 266% of FPL (266 – 322% of FPL for the Medi-Cal Access Program

Children: Up to 266% of FPL

Pregnant individuals Pregnant and post-partum women eligible for pregnancy services or full-scope benefits

Up to 213% of FPL

Also, those with income:

o Up to 60% of FPL are eligible for full-scope Medi-Cal

o From 60% – 213% of FPL are eligible for coverage of pregnancy-related services

o From 100% – 400% of FPL can also choose to enroll in Covered California and receive premium assistance

o From 214% – 322% of FPL are eligible for the Medi-Cal Access Program.

OTHER MEDI-CAL GROUP

Other Medi-Cal groups, often referred to as Non-MAGI Medi-Cal applies to existing participants and programs that do not follow MAGI rules for determining income. An asset test is continued to be required for Medi-Cal beneficiaries.


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Categories includes, but are not limited to, the following individuals:

Ages 65 and older

Blind

Disabled according to Social Security Administration rules

Supplemental Security Income (SSI)/State Supplementary Payment (SSP) recipients

Recipients of refugee assistance

Receiving long-term care (LTC) in a skilled nursing or intermediate care home

Home and Community Based Waiver recipients

Medicare Savings Program participants

Enrolled in California Work Opportunity and Responsibility to Kids (CalWORKS)

Enrolled in a foster care or adoption assistance program

FORMER FOSTER CARE CHILDREN’S PROGRAM

Effective January 1, 2014, the Former Foster Care Children’s Program (FFCCP) will extend coverage to youth up until their 26th birthday, who were in foster care on their 18th birthday, regardless of income. If an applicant previously aged out of the FFCCP, but is under the age of 26, the applicant still qualifies for Medi-Cal benefits up until their 26th birthday. The FFCCP coverage group does not go through the MAGI determination of income. Program eligibility is solely based on:

Participation in foster care in ANY state on their 18th birthday

Currently residing in the state of California

Younger than the age of 26

Beneficiaries who aged out of foster care and are not currently enrolled in Medi-Cal can apply at their local county social services office. When an application is submitted, the applicant’s participation in foster care on their 18th birthday will be verified. If verification cannot be confirmed at the time of application, the applicant must enroll based on self-attestation. The county social service office has 30 days to verify participation in foster care.

Former foster care youth who are unsure of their foster care status on their 18th birthday should call the Foster Care Ombudsman at (877) 846.1602 or email [email protected].

County-specific information for assistance can be found at:

http://www.childrennow.org/uploads/documents/Coveredtil26_CountyContactList.pdf

CITIZENSHIP AND IMMIGRATION STATUS FOR MEDI-CAL ELIGIBILITY

Citizenship or lawfully present immigration status is not a requirement for Medi-Cal eligibility. However, immigration status will determine the type of eligible services an individual may access. To be eligible for full-scope Medi-Cal a consumer must be a US citizen, a US national, a qualified alien in the US, or Permanently Residing Under the Color of Law (PRUCOL) (including Deferred Action for Childhood Arrivals (DACA)).

Eligibility Requirements for Individuals Not Lawfully Present in the US

mailto:[email protected]://www.childrennow.org/uploads/documents/Coveredtil26_CountyContactList.pdf


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The following table lists the status definition, required documentation and program eligibility for those individuals who are not lawfully present in the US or are temporary residents:

Eligibility for Undocumented Immigrants

Undocumented immigrants are not eligible for full-scope Medi-Cal coverage or for coverage through a Covered California health plan. However, if all other requirements are met, including residency, they are eligible for restricted-scope Medi-Cal coverage as the following table outlines:

Status Definition Valid Documentation

Program Eligibility

Undocumented Immigrants

A foreign-born person who does not have a legal right to be or remain in the US

Not applicable Restricted-scope Medi-Cal:

o Emergency-related services

o State-funded long-term care (LTC)

o Pregnancy-related services:

Prenatal care

Labor and delivery

Up to 60 days of post-partum care

Family planning services

Long-term care/kidney dialysis

Medi-Cal Breast and Cervical Cancer Treatment Program (BCCTP)

The Medi-Cal Access Program

Family Planning Access, Care, and Treatment (Family PACT)

Child Health and Disability Prevention Program (CHDP)


Not Lawfully Present Individuals

Permanently Residing Under the Color of Law (PRUCOL)

Deferred Action for Childhood Arrival (DACA)

PRUCOL - documentation from United States Citizenship and Immigration Services (USCIS) showing PRUCOL status

DACA - Form I-210, Form I-797 Notice of Action or a letter or indicating that the alien’s departure has been deferred. Employment Authorization Document (Card), Form I-766) with status code “C-33”

Full-scope Medi-Cal


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CALIFORNIA MEDI-CAL RESIDENCE REQUIREMENTS

To be eligible for Medi-Cal, a consumer must reside in California. Consumers will attest to their address on their online application, which will be used in the verification process. If further address verification is required the following is a list of currently acceptable types of proof of residency for Medi-Cal:

Recent rent or mortgage receipt, or utility bill in the individual’s name

Current motor vehicle driver’s license or identification card issued by the California Department of Motor Vehicles in the individual’s name

Current California motor vehicle registration in the individual’s name

A document showing that the individual is employed or is seeking employment in California

Evidence that the individual has enrolled their children in a school in California

Evidence that the individual is receiving public assistance in California

Evidence of registration to vote in California

NO FIVE-YEAR WAITING PERIOD IN CALIFORNIA FOR LAWFULLY PRESENT INDIVIDUALS

Unlike the federal requirements for Medicaid, to be eligible for Medi-Cal, there is no required five-year waiting period for lawfully present individuals. For example, under current Medi-Cal policy, eligible green card holders can receive full-scope Medi-Cal coverage in California even if they have been in the US for less than five years.

MEDI-CAL ELIGIBILITY DETERMINATION FOR HOUSEHOLD INCOME AND SIZE

MAGI Eligibility Determination

Effective January 1, 2014, federal law modified the way California calculates tax household income for determining Medi-Cal eligibility.

Determining MAGI Medi-Cal Eligibility

Population Income Threshold*

Childless adults, parents and caretaker relatives

138% of the FPL

Pregnant women 213% of the FPL

Children 266% of the FPL

*Includes the 5 percent income variant disregard

NOTE: Under MAGI rules, assets are not considered when determining eligibility.

Household Size Determination for Medi-Cal

Although MAGI is also used to determine eligibility for financial assistance for Covered California health coverage, household size determination differs slightly between Covered California and Medi-Cal:

For Covered California eligibility, the household always consists of the tax filer and all tax dependents.


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For Medi-Cal eligibility, the household may be different from the tax filing unit for three reasons:

1. Married couples living together are always considered to be in the same household whether they file taxes jointly or separately.

2. Children are always considered part of the household in which they live with their parents and siblings, regardless of who claims them as tax dependents.

3. Medi-Cal has special rules for counting pregnant women that include the number of children expected. Thus, a pregnant woman expecting twins in her third trimester could be counted as one person under the Covered California APTC/CSR rules and as three people under Medi-Cal rules.

ELIGIBILITY DETERMINATION PROCESS

The following three-step process is used to determine whether a consumer is eligible for Medi-Cal:

1. Identify the members of the consumer’s family

2. Add the income of qualified household members

3. Compare total tax household income to the FPL

(Note: There are some additional modifications to MAGI that are made when determining Medi-Cal eligibility)

Income Limits

The program income limits vary for different coverage groups for Medi-Cal. For example, children and pregnant women qualify for Medi-Cal at higher income guidelines compared to childless adults.

The following table outlines the eligibility income guidelines for Medi-Cal groups:

Determining Medi-Cal Eligibility

Population Income Limit (up to)

Childless adults (no biological children) 138% of the FPL

Parents and caretaker relatives 109% of the FPL

Pregnant women 213% of the FPL

Children 266% of the FPL

If a family’s tax household income is above the limits for Medi-Cal the applicant will be determined for Covered California with or without financial assistance.

Example: Derek and Michelle are married and seeking coverage for themselves and their 9 year old daughter, Sofia. Michelle is seven months pregnant and recently lost her employer- sponsored coverage due to a layoff. Derek is a landscaper and his projected annual income is $45,000 (225 percent of the FPL). When submitting their Covered California application the family will qualify for different programs. Derek will most likely qualify for Covered California with financial assistance, Michelle will qualify for pregnancy-related coverage through Medi-Cal and Sofia will qualify for Medi-Cal’s TLICP. All programs offer different levels of coverage with


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different out-of-pocket expenses, and satisfy the requirement to have minimum essential coverage.

ENROLLMENT PERIOD AND APPLICATION PROCESSING TIMES

Consumers who are eligible for Medi-Cal may apply for coverage during any month of the year; there is no enrollment deadline. In household in which some members qualify for Medi-Cal and other qualify for Covered California, only one application needs to be completed. It is important to note that consumers, including dependents, who are eligible for Medi-Cal and fail to enroll will also be subject to the tax penalty for being uninsured.

Consumers who successfully enroll into Medi-Cal are eligible for the entire month in which they were found eligible. In some cases, consumers may be able to get coverage right away. However, if a consumer is trying to enroll some household members in Medi-Cal and others in a Covered California health plan, enrollment in Covered California only occurs during the open-enrollment period (unless a qualifying event allows for an application to be submitted during special enrollment).

Note

Some individuals who qualify for Medi-Cal coverage may be eligible for payment of their medical bills up to three months prior to the date of their Medi-Cal application through Retroactive Benefits.

When a consumer is determined eligible for Medi-Cal in a given month, eligibility is in effect for that entire month. In some cases, the consumer may be able to receive Medi-Cal coverage immediately. Consumers whose application requires resolution regarding citizenship or immigration status will be classified as conditionally eligible for Medi-Cal coverage. For more information on eligibility, contact the county’s Health and Human Services Agency at http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.

Application Processing Times

The Medi-Cal eligibility determination process is completed as quickly as possible, with a targeted timeframe of:

45 days following the date of the application or reapplication is filed

90 days following the date of the application or reapplication is filed when eligibility requires establishing disability or blindness

The 45/90-day time period starts on the date of the application, including mail-in applications. Applications are excluded from the 45/90-day minimum processing requirement if the consumer provides partial information or fails to comply with requests for additional information/verification documentation.

PRESUMPTIVE ELIGIBILITY PROGRAMS

Medi-Cal offers programs that provides consumers with temporary immediate coverage before a consumer is formally determined eligible to enroll in a Medi-Cal program. These programs grant consumers with presumptive eligibility (PE), meaning they are considered eligible until determined otherwise.

http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx


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Hospital Presumptive Eligibility Program

On January 1, 2014, the hospital presumptive eligibility (PE) program began providing individuals with temporary, no cost Medi-Cal benefits for up to two months. The following individuals may be eligible for hospital PE benefits:

Children ages 0-18

Parents and caretaker relatives

Pregnant women

Former foster care children 18 to 26 years of age who were in foster care on their 18th birthday

Adults ages 19-64, not pregnant, not on Medicaid, and not part of any group described above

To receive hospital PE benefits, an individual must submit a simplified application online during their hospital stay. Individuals will be notified immediately of their eligibility determination. Also, they will have the opportunity to complete the Covered California online application to ensure that their benefits do not expire after the two-month coverage period. Inquiries regarding the hospital PE program may be directed to: [email protected].

Presumptive Eligibility for Pregnant Women

Presumptive eligibility for pregnant women is a no cost Medi-Cal program designed to provide immediate, temporary coverage for prenatal care to low-income pregnant women pending submission of a formal Medi-Cal application.

Any woman, who thinks she is pregnant, has a tax household income at or below 213 percent of the FPL and does not have an existing Medi-Cal case may qualify for PE coverage. However, she must seek care through a participating PE provider. PE is temporary coverage up to 2 months (during the month the women applies for PE through the end of the following month).

PE coverage offers specific out-patient prenatal care, out-patient abortion procedures, prescription drugs for conditions related to pregnancy, and limited preventive dental services. However, it does not cover labor and delivery, family planning or inpatient care. Therefore, PE patients must submit a formal Medi-Cal application to continue receiving coverage. For questions about the PE program, contact the PE Support Unit at (800) 824-0088.

Medi-Cal Express Lane Eligibility

Express Lane Eligibility is a result of federal guidance to streamline Medi-Cal enrollment for newly eligible adults and children. Newly eligible adults and children currently enrolled in the CalFresh program who are not receiving Medi-Cal will use Express Lane Eligibility to expedite the Medi-Cal enrollment process.

A federal waiver allows DHCS to grant Medi-Cal eligibility without the need for an application or a determination for 12 months by using CalFresh income eligibility for enrolled adults and children. By being enrolled in CalFresh, income and residency has been established and DHCS will only need to conduct necessary citizenship and identity verifications to comply with federal Medicaid regulations. For more information on Express Lane Eligibility please visit: http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ExpressLane.aspx.

MEDI-CAL ESTATE RECOVERY PROGRAM

Because Medi-Cal pays for medical care for some people whose savings and income are too low for them to be able to pay for their own care, the cost of the consumer’s medical care or the cost of the premiums paid for care may be required to be repaid to Medi-Cal upon the

mailto:[email protected]://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ExpressLane.aspx


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consumer’s death. Repayment is never more than the value of the assets the consumer had at the time of death. The amount repaid can then be used to pay for medical care for others who need it.

After receiving notification regarding the death of a person who received Medi-Cal benefits, the Department of Health Care Services (DHCS) will decide whether or not the cost of services must be paid back. Also considered, is the amount that has been paid by Medi-Cal and what is left in the estate of the deceased who received services. Regardless of what is owed in services, the total value collected will never be more than the value of assets owned by the consumer at the time of their death.

The DHCS cannot require reimbursement under the following circumstances:

During the lifetime of a surviving spouse

For Medi-Cal services provided before the consumer’s 55th birthday (unless the consumer is institutionalized)

If the consumer is survived by a child under 21 years of age

If the consumer is survived by a child who is blind or disabled (as defined by the Federal Social Security Act)

The result of reimbursement would cause substantial hardship to the deceased dependents, heirs or survivors

For more information on estate recovery please visit: http://www.dhcs.ca.gov/formsandpubs/publications/Pages/BrochuresMedi-Cal.aspx

CHILD HEALTH AND DISABILITY PREVENTION PROGRAM

The Child Health and Disability Prevention (CHDP) is a federal and state supported heath program that provides periodic health assessment for the early detection and prevention of disease and disabilities for low-income children and youth. CHDP provides care coordination to assist families with medical appointment scheduling, transportation, and access to diagnostic and treatment services. Health assessments are provided by enrolled private physicians, local health departments, community clinics, managed care plans, and some local school districts.

Children are eligible from birth through the age of 18 if not enrolled in Medi-Cal; Medi-Cal participants are eligible up to the age of 21. Children in Head Start and Preschool programs are also eligible. The CHDP income limit is up to 213 percent of the FPL, and assets or immigration status are not taken into consideration. If a child qualifies for CHDP, there is no cost for services to the family. The program offers periodic child health assessments/examinations, whose frequency is determined by the child’s age, which include:

Health and developmental history

Complete physical examination

Oral health assessment

Nutrition assessment

Behavioral assessment

Immunizations

Vision screening

Hearing screening

Laboratory tests for anemia, blood, lead, tuberculosis, urine abnormalities, sexually transmitted diseases, and other problems as needed

Health education and anticipatory guidance

http://www.dhcs.ca.gov/formsandpubs/publications/Pages/BrochuresMedi-Cal.aspx


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To access CHDP families must contact a CHDP provider. To find providers please visit: http://www.dhcs.ca.gov/services/chdp/Pages/countyoffices.aspx.

CONCERNS OR COMPLAINTS

Consumers covered under regular (fee-for-service) Medi-Cal who have a complaint may contact their local county social services office for help. For a complete listing of offices and phone numbers, contact the DHCS, www.dhcs.ca.gov, or call (916) 445.4171. Consumers in a Medi-Cal managed care plan may contact either the Medi-Cal Managed Care Ombudsman at (888) 452.8609, or the Department of Managed Health Care at (888) 466.2219, to report a complaint.

6 ELIGIBILITY AND ENROLLMENT FOR AMERICAN INDIANS AND ALASKA NATIVES

There are special eligibility standards for American Indians and Alaska Natives, sometimes referred to by the acronym (AI/AN). The term applies to any individual who is:

Is a member of a federally recognized tribe by the US Bureau of Indian Affairs (BIA), in the US Department of Interior

The definition of Indian relative to its use regarding Covered California and the Affordable Care Act is different than its use relative to other federally supported health services to American Indians under Medi-Cal and CHIP. Therefore, enrollment assistance personnel should be aware that individuals may be deemed an American Indian for one program and not the other, resulting in different eligibility outcomes. For purposes of Covered California eligibility, American Indians and Alaska Natives are recognized if they are:

A member of a federally-recognized tribe by the United States Bureau of Indian Affairs

(BIA) in the U.S. Department of the Interior

First or second descendants of tribe members as described in the point above

An Eskimo or Aleut or other Alaska Native

Considered by the Secretary of the Interior to be an Indian for any purpose.

Determined to be an Indian by the Secretary of Health, Education and Welfare in collaboration with the Department of Health and Human Services

The following table summarizes the eligibility and enrollment standards as they are applied with Covered California for American Indians and Alaska Natives:

Eligibility and Enrollment Standards for American Indians and Alaska Natives

Standard Requirements

Eligible for cost-sharing elimination if: Tax household income is less than 300% of FPL for the benefit (coverage) year

Enrolled in a Covered California health plan

Receives care from another health care program

http://www.dhcs.ca.gov/services/chdp/Pages/countyoffices.aspxhttp://www.dhcs.ca.gov/


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Eligibility and Enrollment Standards for American Indians and Alaska Natives

Standard Requirements

Individual mandate tax penalty Exempt under all circumstances

Enrollment periods Can enroll year-round

May change coverage Once a month

ELIGIBILITY FOR THE ELIMINATION OF COST-SHARING EXPENSES

American Indians and Alaska Natives who enroll in a Covered California health plan do not have to pay copays or cost-sharing expenses if they expect to have a tax household income that does not exceed 300 percent of the FPL for the benefit year during which coverage is requestedi.

If these individuals are enrolled in a Covered California health plan, any cost-sharing is eliminated if a service is provided directly by:

The Indian Health Service

An Indian tribe

A tribal organization or urban Indian organization

Through a referral under contracted health services

The table below describes the special Indian provisions for eligibility in health coverage options:

Health coverage option Who is eligible Special Indian provisions

Medicare Over 65 years old. Also, those of any age with kidney failure

Medi-Cal Under 138% of the FPL No premium

No co-pay/deductible

Child Health Insurance Program (CHIP)

Children under 19 years of age with family income under 266% of the FPL

No premium

No co-pay/deductible

Covered California health plan

Under 65 years of age who are not eligible for Medi-Cal and CHIP

No co-pay/deductible*

(if income is below 300% of the FPL or consumer receives services through an Indian Health Program)

*Special monthly enrollment provisions are limited to members of a federally recognized tribe


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There is no CSRs for American Indians or Alaska Natives, who are members of a federally recognized tribe, for any item or service received from an Indian Health Program including Tribal and Urban Indian Organizations or through referral under contracted health services, regardless of tax household income.

EXEMPTION FROM INDIVIDUAL MANDATE PENALTIES

American Indians, who are members of a federally recognized tribe or are eligible for services through an Indian Health Service provider and Alaska Natives are exempt from individual mandate (shared responsibility) tax penalties. Members of a federally recognized tribe can access the exemption through the IRS.

Once granted, it is a lifetime exemption, unless tribal eligibility status changes. Further, the exemption does not prevent the consumer from enrolling in Covered California, Medi-Cal or other health coverage programs.

ENROLLMENT PERIODS

American Indians, from a federally recognized tribe, and Alaska Natives do not have the same open-enrollment restrictions as the general population. They are able to enroll in health coverage year round and may switch health plans up to once per month.

Allows for unrestricted navigation between Indian Health Service coverage and Covered California in order to access care not available at Indian Health Service providers, such as medical specialists, hospitals and surgical care.

Allows for unrestricted navigation between health plans and metal tiers to access different premium levels and provider networks based on medical need.

Enrollment and effective dates for American Indian/Alaska Natives follow the same guidelines as other Covered California health plans (discussed previously in this course).

VERIFICATION OF STATUS

If a consumer attests that they are an American Indian or Alaska Native (or included in one of the other categories defined above), Covered California must verify this attestation against available data sources. If additional documentation is required, the consumer has 90 days to provide it to Covered California. Acceptable documentation includes:

Tribal Identification Card

BIA Form

Certificate of Degree of Indian Blood (CDIB)

7 PROCESSES FOR REFERRALS, APPEALS AND COMPLAINTS

REFERRALS TO NON-COVERED CALIFORNIA HEALTH PROGRAMS

The online application through CoveredCA.com supports referrals to non-Covered California health programs by asking, “Would anyone in the household like a referral to the local Health and Human Services Agency for any of the following programs: CalWORKS or CalFresh?”

Consumers who answer “yes” will be provided the contact information for the nearest agency. Their application will also be forwarded to CalWORKS/CalFresh, and these agencies will follow up with the consumer to obtain additional information and help them apply for benefits. The referral process also applies to cases where the consumer requests a referral for non-MAGI


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Medi-Cal coverage. For information on CalWORKS go to: http://www.cdss.ca.gov/calworks/ . For information on CalFresh go to: http://www.calfresh.ca.gov/ .

CONSUMER APPEALS PROCESS

Covered California has an appeals process for consumers who disagree with any of the following:

Their eligibility determination for a Covered California health plan or Medi-Cal coverage

Determination of the premium assistance amount or cost-sharing reductions they should receive

Annual redetermination of eligibility

Eligibility determination for an individual mandate exemption based on: hardship, religious beliefs, membership in a ministry, incarceration, being an American Indian or Alaska Native

Appeals Process Steps

The appeals process steps are:

Step 1: Consumers have 90 calendar days from the notice date of a Covered California or Medi-Cal determination to submit an appeal.

Step 2: Covered California/Medi-Cal has 90 calendar days from the date the appeal is submitted to take the appeal under consideration and settle it accordingly. (The 90-day time frame is dependent on federal regulators providing a response to Covered California.) During this 90-day period, Covered California will:

Work closely with the consumer to resolve the issue on an informal basis

Schedule and hold a formal hearing to settle the appeal if the appeal cannot be resolved on an informal basis

Step 3: If consumers are not satisfied with the appeal hearing decision related to premium assistance or cost-sharing reductions, they can file an appeal directly with the DHHS.

SUPPORT FOR CONSUMERS WITH CONCERNS OR COMPLAINTS

Covered California is committed to supporting consumers who call the Covered California Service Center at 800-300-1506 with any concerns or complaints. There are a number of other California state resources available to support consumers.

The Office of Patient Advocate (www.opa.ca.gov). The agency’s toll-free number is 866-466-8900. This state agency provides:

A very useful overview of the health care industry

A glossary of terms

Education in patient rights

A step-by-step guide that explains to consumers how to deal with a problem or file a complaint against their health care insurance company

http://www.cdss.ca.gov/calworks/http://www.calfresh.ca.gov/file:///C:/Users/BPedell/Desktop/RHA/Eligibility%20for%20Individuals%20and%20Families/www.opa.ca.gov


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California Department of Managed Health Care (DMHC) (www.dmhc.ca.gov): This state agency oversees HMOs and some PPOs. Consumers can contact the DMHC if they have filed a complaint against their health insurance plan because it denied coverage based on lack of medical necessity, or regarding treatment that is considered experimental or investigational in nature. The agency’s toll-free number is 888-466-2219.

California Department of Insurance (CDI) (www.insurance.ca.gov): This state agency handles complaints against PPOs, and it functions in the same manner as the Department of Managed Health Care. Consumers can file a complaint with the CDI against their PPO if coverage was denied based on lack of medical necessity, or regarding a treatment that is considered experimental or investigational in nature. The agency’s toll-free number is 800-927-4357.

http://www.dmhc.ca.gov/http://www.insurance.ca.gov/


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8 ENDNOTES

i Code of Federal Regulations, Part 155 — Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act [45 CFR 155], § 155.350 (a)(ii)

Sources

MedlinePlus, a service of the US National Library of Medicine, National Institutes of Health. Accessed at www.nim.nih.gov

www.dhcs.ca.gov for Medi-Cal benefits

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HealthReformTranslationMAGI.pdf for Medi-Cal benefits information

Medi-Cal Program Guide Special Notice (SN) 13-09, Addendum A, December 09, 2013

National Health Law Program, Youth Law Center, October 2013 (for foster care youth information) http://www.healthlaw.org/component/jsfsubmit/showAttachment?tmpl=raw&id=00Pd0000007APpIEAW
http://www.nim.nih.gov/http://www.dhcs.ca.gov/http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HealthReformTranslationMAGI.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HealthReformTranslationMAGI.pdfhttp://www.healthlaw.org/component/jsfsubmit/showAttachment?tmpl=raw&id=00Pd0000007APpIEAWhttp://www.healthlaw.org/component/jsfsubmit/showAttachment?tmpl=raw&id=00Pd0000007APpIEAW

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