Medi-Cal Handbook FPL Programs 36. FPL Programs · FPL Programs 36. FPL Programs ... (OBRA), with a...

Medi-Cal Handbook page 36-1FPL Programs

36. FPL Programs

36.1 60-Day Postpartum Program

36.1.1 Program Overview

The 60-Day Postpartum Program provides no share of cost (SOC) restricted pregnancy related and postpartum services for certain eligible pregnant women. The Postpartum Program became effective January 1, 1988. 60-Day Postpartum benefits can be approved only when the woman is not otherwise eligible for Medi-Cal under another program with No-SOC.

Services during the postpartum period for conditions which are not related to the pregnancy are not covered by the 60-day program. The decision of whether or not a service is “pregnancy related” will be made by the physician on a case-by-case basis.

Aid Code “76” is used for the restricted 60-Day Postpartum Program.

36.1.2 Eligibility Requirements

A pregnant woman who was eligible for and received Medi-Cal during the last month of pregnancy continues to be eligible for all pregnancy-related and postpartum services for a 60 day period, regardless of whether the other conditions of Medi-Cal eligibility are met.

In order to receive postpartum benefits, eligible women must:

• Have applied for Medi-Cal, and• Been eligible for Medi-Cal, and• Have received Medi-Cal benefits on their last day of pregnancy.• Have met their SOC for the month the pregnancy ends before postpartum

benefits are approved.

The 60-Day Postpartum Program is not available to any woman who receives retroactive Medi-Cal coverage in the month in which pregnancy ends.

Services are restricted to pregnancy related and postpartum care.

Update # 15-06 Revised: 2/20/15

page 36-2 Medi-Cal HandbookFPL Programs

36.1.3 Period of Eligibility

• Eligibility begins on the first day of the month following the month pregnancy ends, and

• Ends on the last day of the month in which the 60th day occurs.

36.1.4 Dual Eligibility and Postpartum

A woman may have dual Medi-cal eligibility, that is:

• Postpartum coverage which provides 60 days of no-share-of-cost benefits for her pregnancy related and postpartum services only, and

• Full-scope Medi-Cal benefits, or restricted Medi-Cal for other emergency care (OBRA), with a share of cost (SOC).

The SOC must be met for the month the pregnancy ends before postpartum benefits are approved. [Refer to “Women Ineligible for 60-Day Postpartum,” page 36-5]

36.1.5 Pregnancy Definition/Verification Requirements

These regulations apply to full-term pregnancies, as well as to pregnancies ending by miscarriage or by therapeutic abortion.

As eligibility for postpartum is time limited and ends on the last day of the month in which the 60th day occurs:

• The last day of pregnancy must be verified.

• Verification includes, but is not limited to the newborn's birth certificate, hospital bill/statement of childbirth, appointment notice for termination of pregnancy, etc.

• If the client has no verification available, use a General Affidavit (SC 101.)

• No other conditions or eligibility requirements must be met.

Revised: 2/20/15 Update # 15-06


36.1.6 Women Eligible for 60-Day Postpartum

The following groups of pregnant women are entitled to benefits under this program unless otherwise eligible for Medi-Cal benefits with no share of cost under any other program:

Medically Indigent (MI) Women (e.g. Aid Code 86, 87)

• Postpartum benefits begin on the first day of the month following the month pregnancy ends, and end on the last day of the month in which the 60th day occurs.

• If there is a share-of-cost (SOC), the SOC must be met for the month pregnancy ends before postpartum benefits are approved.

EXAMPLES:

(1) SOC - MI: Mary delivers her baby on 10/25 and meets her SOC in October. A NOA is sent on 10/28, but due to the 10-day notice requirement, her eligibility for Medi-Cal coverage with a SOC continues until 11/30. She does not meet her SOC in November; however, she is still entitled to receive postpartum coverage and is approved for no-SOC Aid Code “76” Medi-Cal benefits for November. As the last day of pregnancy is 10/25, and the 60th day following is 12/23, her no-SOC postpartum eligibility ends on 12/31.

(2) No SOC - MI: Gina delivers her baby on 10/5. She continues to be eligible for Medi-Cal coverage under MI, aid code 86 until 10 /31. A timely 10-day NOA is sent, her MI eligibility is terminated and eligibility for the no-SOC postpartum program begins on 11/1, by which date 28 days of the postpartum program have already elapsed (the 60 days begin on the last day of pregnancy). As the 60th day from the last day of pregnancy falls on 12/3, her eligibility for pregnancy related and postpartum services ends 12/31. During this time she is approved for no-SOC Aid Code “76” Medi-Cal benefits. If she had delivered on 10/2, the 60th day from the last day of pregnancy would have fallen on 11/30, and her no-SOC postpartum eligibility would have ended on the same date.

Medically Needy (MN) Women (e.g., Aid Code 34, 37)

An MN woman with a SOC.



(1) The SOC must be met during the month pregnancy ends.

(2) Eligibility for Medi-Cal benefits with a SOC will normally continue after pregnancy ends.

(3) Should this woman meet her SOC in a postpartum month, she will have dual coverage, (e.g., MN/SOC coverage, and no-SOC 60-Day Postpartum benefits).

An MN woman with no-SOC who, due to a change in circumstances either:

(1) Loses her Medi-Cal eligibility, or

(2) Remains Medi-Cal eligible but goes from no-SOC to SOC status at any time during the 60-day period beginning on the last day of pregnancy.

Public Assistance (PA) or Other PA Recipient (TMC)

When a Public Assistance (PA) or Other PA recipient (TMC) is discontinued from cash due to a change in circumstances, loses her Medi-Cal eligibility or remains Medi-Cal eligible with a SOC, then:

• Issue full-scope Medi-Cal benefits if eligible under any other program. (e.g., TMC, Edwards v Kizer, AFDC-MN or MI.)

• Coverage under the 60-Day Postpartum Program begins on the first day of the first month in which Medi-Cal ineligibility, or eligibility with a SOC begins, and ends on the last day of the month in which the 60th day occurs.

Minors, Whose Pregnancy Terminates

• An MI child with a SOC (83) is eligible for the 60-Day Postpartum Program, as long as the SOC is met during the month pregnancy ends.

• A child receiving Minor Consent Services with NO SOC continues to be eligible for pregnancy related and postpartum care under the Minor Consent program; therefore, 60-Day Postpartum benefits must not be issued.

• If the Minor Consent eligible child has a SOC and the SOC is met for the month pregnancy ends, 60-Day Postpartum benefits must be issued. The paper BIC must be issued as an immediate need, as nothing is to be mailed to the home.



36.1.7 Women Ineligible for 60-Day Postpartum

The following women are not eligible for the 60-day Postpartum Program:

• Any woman who receives retroactive Medi-Cal in the month in which pregnancy ends is not eligible.

Example:A family applies for Medi-Cal April 4th and requests RETRO for February and March. Their child was born February 10th. The mother is not entitled to 60-Day Postpartum benefits.

• Any woman who has a share of cost which is not met and who does not have Medi-Cal certified for the month that pregnancy ends is not eligible.

• A woman who is not eligible for Medi-Cal benefits for the month pregnancy ends.

• Women who receive other zero SOC Medi-Cal with full scope benefits, restricted benefits, or a poverty level program for pregnant women are not eligible and do not need coverage under the Postpartum Program.

• Women who are eligible for pregnancy related services under the Minor Consent Program, unless the minor has a SOC.

Exception:Eligibility for 60-day postpartum benefits under the 200% Income Disregard or Property Waiver Program can be established retroactively. [Refer to “Dual Eligibility and Postpartum,” page 36-2]

Note:Postpartum and pregnancy related services are only for the pregnant woman. Medical services provided to the newborn ARE NOT covered by the restricted status Aid Code 76.



36.1.8 Issuing Postpartum When Pregnancy Ends

When notified of a birth or the termination of a pregnancy, the EW must evaluate the woman's eligibility for Medi-Cal benefits.The following procedures apply:

If... Then...

Discontinuing Medi-Cal, • Give a timely and adequate 10-day NOA.

• If the client reports new information entitling her to continuing Medi-Cal benefits, an interprogram status change must be completed.

• Continue Medi-Cal with a SOC if otherwise eligible, e.g., Aid Code 37.

• Evaluate eligibility for the newborn.• Verify the last day of pregnancy.• If the client is eligible, CalWIN will

establish Postpartum Aid-Code “76”. • No online approval is needed.

CalWIN will generate the appropriate Add transaction to MEDS.

Discontinuing a pregnant woman who was CalWORKs eligible or had no SOC Medi-Cal in the month pregnancy ends,

• No online approval is needed.CalWIN will generate the appropriate Add transaction to MEDS.

• Discontinue postpartum eligibility the last day of the month in which the 60th day occurs.

Discontinuing a pregnant woman who had a SOC in the month pregnancy ends, and is no longer eligible (87),

• Discontinue Medi-Cal benefits.• Do not approve restricted Postpartum

benefits until the SOC has been met for the month pregnancy ends.

• CalWIN will establish Postpartum Aid Code 76 once the EW has indicated the SOC has been met.

• CalWIN will issue the Postpartum Approval Notice.

• No online approval is needed. CalWIN will generate the appropriate Add transaction to MEDS.

• Discontinue Aid Code 76 the last day of the month in which the 60th day occurs. CalWIN will generate the appropriate EW 40 transaction to terminate Aid Code 76.

(Chart page 1 of 2)



36.1.9 Discontinuance of 60-Day Postpartum Benefits

Eligibility for Postpartum ends on the last day of the month in which the 60th day from the last day of pregnancy falls.

Example:When the 60th day after the termination of pregnancy ends in mid-month, eligibility continues through the last day of that month.

EWs must evaluate eligibility for continuing Medi-Cal coverage at any time during the 60-Day Postpartum period:

• Reevaluate any new information reported by the client.

• Make the appropriate changes, if new information is reported which entitles the client to other Medi-Cal benefits.

• Evaluate eligibility for the newborn.

• When the SOC has been met for the month pregnancy ends, issue 60-Day Postpartum benefits.

Medi-Cal continues with a SOC, and the pregnant woman is eligible for Postpartum,

• Continue Medi-Cal benefits with a share-of-cost.

• Do not approve restricted Postpartum benefits until the SOC has been met for the month pregnancy ends.

• CalWIN will establish Postpartum Aid Code 76 once the EW has indicated the SOC has been met and generate the Postpartum Approval NOA.

• CalWIN will generate the appropriate Add Transaction to MEDS.

• Discontinue Aid Code 76 the last day of the month in which the 60th day occurs.CalWIN will generate the appropriate EW 40 transaction to terminate Aid Code 76.

Advise the pregnant woman of her entitlement to 60-Day Postpartum no SOC benefits and of her responsibility to report when she has met her SOC so that postpartum benefits may be issued.

If... Then...

(Chart page 2 of 2)



Important:

The client does not have to request postpartum benefits in order to receive restricted, no-share-of-cost benefits.



36.2 Income Disregard Program

36.2.1 Who is Eligible

The Income Disregard Program is a special program which provides Medi-Cal with no share of cost to certain otherwise eligible pregnant women and infants under the age of one year.

To initially qualify under this program, net nonexempt family income must be over the Maintenance Need Level, but not in excess of 200% of the Federal Poverty Level (FPL).

Exception:When a parent/caretaker relative applies for Medi-Cal on behalf of a pregnant minor who is living in the home, all of the parent(s) income is disregarded if the pregnant minor is not eligible for the 200% program using regular rules. This provision includes pregnant minors, ages 18 - 21 who are being claimed as tax dependents by their parents, even though they do not live in their parents’ home. [Refer to “Pregnant Minors, Parental Income Disregard,” page 36-13.]

• Only those cases with a share-of-cost (SOC) are potentially eligible for the Income Disregard Program.

Note:A pregnant woman or infant whose income is at or below 200% of the FPL are potentially eligible for the Property Waiver Provision of the Income Disregard Program. [Refer to “Scope of Coverage,” page 36-42].

• Allow applicable AFDC-MN/MI income deductions.

• Private health insurance premiums are NOT an allowable deduction when determining if family income is at or below the federal poverty level.

The Income Disregard Program does not require a separate application. Eligibility for this program is determined as part of the MN/MI application.

Reminder:Eligible pregnant women are considered as an immediate need.



36.2.2 Background

The Income Disregard Program began as two separate programs:

• The 185% Program, which began on 7/1/89, and

• The 200% Program, which began on 10/1/89.

Originally, the state received federal financial participation (FFP) only for 185% Program eligibles. However, the state later discovered a provision in federal law which allows for an income disregard of the difference between 200% and 185% of the federal poverty level (FPL) for the family size. This results in more persons being eligible under the 185% Program. The 185% Program is renamed to the “Income Disregard” Program.

Note:Income Disregard Program Person Aid Codes are used for both the Income Disregard and the Property Waiver Programs.

36.2.3 Retroactive Benefits

Eligibility for the Income Disregard Program, including 60-day postpartum benefits, can be established retroactively.


Pregnant Women

Eligibility can begin no earlier than the first day of the month for which pregnancy is verified. Eligibility continues through the 60-day postpartum period which:

• Begins on the last day of pregnancy, and• Ends on the last day of the month in which the 60th day occurs.

Women who are eligible for this program receive their postpartum Medi-Cal benefits issued under the Income Disregard Program Aid Code instead of Aid Code 76.

Discontinue the Income Disregard Program at the end of the 60-day postpartum period.



Infants

Otherwise eligible infants can receive benefits under this program though the month that they turn age one (13 months).

Exception:An infant who is receiving inpatient medical services for a continuous period, which begins before and continues beyond the baby's first birthday, remains eligible under the Income Disregard program until the end of the continuous stay. Hospitalized infants remain eligible until they are actually discharged. Temporary home visits do not affect their eligibility. [Refer to “Hospitalized Infants,” page 36-28 for card issuance procedures.]

MEDS Renewal will automatically generate CEWA '9525' within two (2) months of the end of the infant's qualifying period (11 months old). The month in which the infant reaches 1 year, CEWA '9526' will be generated by MEDS. The record will be terminated by MEDS at Renewal if no termination transaction is received from the county. [Refer to User’s Guide to State Systems Handbook, “9526 - Infant/Child Elig Terminated - Check for Exception Elig - Action,” page 11-62] for instructions on how to reactivate the infant.]

36.2.5 Scope of Benefits and Aid Codes

Pregnant Women

Pregnant women have dual Medi-Cal eligibility:

• No-share-of-cost Medi-Cal benefits for all of their pregnancy related services (including prenatal care, labor, delivery, services related to pregnancy complications, postpartum care, and family planning), AND

• A share of cost under the AFDC-MN/MI Program for their nonpregnancy care.

Aid codes for the Income Disregard Program are determined according to citizenship/alien status:

Aid Code Description

44 Citizen/lawful permanent resident, PRUCOL, or conditional resident (a noncitizen who is otherwise eligible for full scope benefits

48 Undocumented status or temporary Visa (OBRA).



Infants

Otherwise eligible infants receive only full-scope Medi-Cal benefits.

Exception:An undocumented infant or one who has a temporary, unexpired visa is only eligible for emergency care.


47 Citizen/lawful permanent resident alien, PRUCOL, or conditional resident.

69 Undocumented status or temporary visa (OBRA).

36.2.6 Income Determination, Budgeting

Follow these steps to determine eligibility for the Income Disregard Program:

Step Action

1 Determine the individual/family's eligibility under the regular Section 1931(b) or the AFDC-MN/MI Program.

2 Determine eligibility for Federal Poverty Level programs under regular FPL or Sneede FPL if the MFBU includes a Sneede class member, and the case has BOTH:

• A share of cost, AND • A pregnant woman and/or child under the age of one year.

3 Include all family members in the MFBU (eligible and ineligible persons) when determining the Maintenance Need and Poverty Level. (Do not count excluded persons or PA recipients.)

4 Allow only AFDC-MN/MI deductions when computing the net nonexempt family income for the Income Disregard Program.

Exceptions: Health insurance premiums are NOT an allowable deduction. Also, if the MFBU includes an ABD-MN person, only AFDC-MN/MI deductions are allowed for the Income Disregard Program.

5 Repeat these steps if income changes and/or new information is received which affects the share of cost or persons eligible.

Note:Rules pertaining to the treatment of income are not changed by the Income Disregard Program. Apply the usual income determination rules as appropriate. For example, convert weekly or biweekly income to monthly, average fluctuating income, apply prospective budgeting and so on.



36.2.7 Pregnant Minors, Parental Income Disregard

Effective January, 2002, the “parental income disregard provision” applies when a parent/caretaker relative applies for Medi-Cal on behalf of a pregnant minor living in the home. All of the parent(s) income is disregarded IF THE PREGNANT MINOR IS NOT ELIGIBLE FOR THE 200% PROGRAM USING REGULAR RULES.

In most cases, the EW will apply the parental income disregard first, unless it is more beneficial to family members to use regular Income Disregard rules.

Exception:In most senior parent - minor parent households, it is the senior parent(s) who usually have the most income, but not always. Sometimes it can be more beneficial to use regular Income Disregard rules. For example, the minor mother and the unborn’s father have income, but her parent(s) have little income or there are siblings in the home which increases the family size and income limit. (Clearly document the reason in Maintain Case Comments).

Note:Sneede rules apply if the pregnant minor has income.

The disregard does not have to be applied if the pregnant minor is eligible under the regular Income Disregard Program. The original 200% Income Disregard Program is not eliminated by this change. The parental income disregard is applied if the minor will have a SOC when her parent’s income is counted.

• This provision includes pregnant minors, ages 18 - 21 who are being claimed as tax dependents by their parents, even though they do not live in their parents’ home.

• Only the net non-exempt income of the pregnant minor, the unborn’s father, or the minor mother’s spouse is counted when determining eligibility.

• If the pregnant minor’s parents apply for her and provide the necessary information about the minor but refuse to provide information about themselves, the eligibility determination can be made for the minor without it.

• The Minor Consent Program is not changed by this provision. Pregnant Minors may still choose to receive confidential pregnancy services under the Minor Consent Program.

[Refer to “MFBU Examples,” page 36-16 for MFBU/budgeting examples of pregnant minors living with their parents and the parental income disregard.]



36.2.8 Approvals & Denials

Use this chart to determine the appropriate Approval/Denial actions. These rules apply both to new applications and continuing cases.

If net non-exempt income of the MFBU is... Then...

At or below Maintenance Need Approve under the regular AFDC-MN/MI program.

Between Maintenance Need and 200% of FPL Approve pregnant woman under the Income Disregard Program for her no SOC pregnancy services. She is also eligible for non-pregnancy care with a SOC.

Approve eligible infants under the Income Disregard Program.

Over 200% of FPL but under 266% of FPL, and pregnant individual is under 19 years of age

Deny the Income Disregard Program. Approve appropriate aid code under the Optional Targeted Low Income Children (OTLIC) Program. Delete the denial NOA for the Income Disregard Program.

Approve eligible infants under the OTLIC.

Over 200% of FPL but under 266% of FPL, and pregnant individual is over 19 years of age

Deny the OTLIC. Approve AFDC-MN/MI with a share of cost. Explore Medi-Cal Access Program (MCAP) eligibility.

Approve eligible infants under the OTLIC or MCAP.

Over 266% of FPL Deny the OTLIC. Approve AFDC-MN/MI with a share of cost. Explore California Children’s Health Initiative Program (CCHIP) or MCAP.

Delete the denial NOA for the OTLIC.

36.2.9 Exceptions

Continued Eligibility

Under Continued Eligibility rules, once a pregnant woman has been approved for Medi-Cal, increases in income are not applied to the SOC determination for her pregnancy-related services, until the end of her 60-day postpartum period. Also,

Note:



increases in the family's income are not counted in the newborn's SOC determination until the child reaches age one. [Refer to “Continued Eligibility for Pregnant Women, Infants, and Children [50262.3],” page 22-1.]

Property Waiver Program

Pregnant women and infants who choose and qualify for the Property Waiver Provision of the Income Disregard Program, remain eligible under the Property Waiver Program, even though their income later increases or decreases. [Refer to “Income Increases,” page 36-47.]

Reminder:When a case has excess property or a share-of-cost AND the MFBU contains a Sneede class member, Sneede rules must be applied. [Refer to “Court Orders: Sneede v Kizer,” page 70-1 and “Property Waiver Program,” page 36-40.]

36.2.10 MFBU Requirements

Pregnant Women

An Income Disregard Program eligible pregnant woman must always be included with the unborn as an eligible person in two MFBUs:

1. The Income Disregard Program MFBU (No share of cost), and

2. The MN/MI MFBU (share of cost).

Infants

An infant receives no-share-of-cost Medi-Cal benefits under the Income Disregard Program MFBU, either full-scope or restricted.

• The infant is also included in the AFDC-MN/MI MFBU so the correct Maintenance Need level is allowed for other Medi-Cal eligible family members.

• When discontinuing an infant from the Income Disregard Program because he/she has turned age one, evaluate the child's eligibility for the 133% Program or TLICP.



36.2.11 MFBU Examples

1. PARENTS, CHILDREN AND UNBORN (NO DEPRIVATION)

A married couple, both age 25, are applying for Medi-Cal because mom is pregnant. They have two other children, a 7 month old boy, and a girl, age 5. They have no private health insurance. Dad is fully employed with net non-exempt monthly earnings of $3000. *Example uses FPL income limits effective 12/01/12.

Number in MFBU 5

Maintenance Need Level $1259

Income Disregard Program (200%) $4,502

133% Program $2,994

TLICP 150% $3,377

INCOME DISREGARD PROGRAM MFBU

MI MFBU (5)

Pregnant Woman Pregnant Woman (eligible for non-pregnancy care with a SOC, Aid Code 87)

Unborn Father (include as an ineligible person)

infant (age 7 months) Child, age 5 (eligible, Aid Code H2)

Infant (include as ineligible person)

Unborn

• The infant, age 7 mos., receives full scope no SOC Medi-Cal benefits under the 200% Income Disregard Program until he reaches age one.

• The 5 year old child is ineligible for the 133% but is eligible for the TLICP for children age 1-5 with the family income up to 150% FPL.

• When the baby is born, the newborn will be eligible for the Income Disregard Program. Mom will no longer be eligible for Medi-Cal after her 60-day postpartum period ends (there is no deprivation). Her postpartum benefits are issued under the Income Disregard Program Aid Code.



2. UNMARRIED PREGNANT MINOR LIVING WITH HER PARENTS.

An unmarried pregnant minor age 17, lives with her parents. The minor is not deprived and the family is not eligible for Section 1931(b) or MN. The pregnant minor is eligible for the Income Disregard Program with the parental income disregard.

Example uses FPL income limits effective 12/01/12.

MI Program MFBU **Parental Income Disregard Provision

Pregnant Minor’s Father (IE)

$2,000 Pregnant Minor $500

Pregnant Minor’s Mother (IE)

$1,500 Unborn 0

Pregnant Minor $500 Total $500

Unborn 0 200% FPL Limit (2) $2,522

Total $4,000

** The regular “Income Disregard Program” rules are not applied, as the combined family income exceeds 200% FPL limit for 4 persons ($3,842).

Maintenance Need (4) $1,100

*SOC $2,900

*Next, Sneede rules apply because the minor mother has income. The minor mother’s MBU would still have a SOC due to her own income and the allocation from her father. (The Sneede budget computation is not shown in this example.)

The minor is reported to MEDS with a Secondary Aid Code of 44 for pregnancy-related services only. She will have a SOC in the MI program for non-pregnancy services with a Primary Aid Code of 83. If she did not have satisfactory immigration status (SIS), she would be reported to MEDS with a secondary Aid Code 48, with a Primary Aid Code of wither 58 or 5F.



3. UNMARRIED PREGNANT WOMAN, AGE 17, LIVING WITH HER MOTHER

The senior parent is applying for Medi-Cal for herself and her daughter, age 17, who is pregnant, and is in her last trimester. First, determine eligibility for Section 1931(b), as there is absent parent deprivation. The senior parent’s net non-exempt monthly income is $1,200.

The parental income disregard provision has no impact in this scenario, as the senior parent and her daughter are eligible for Medi-Cal with no SOC under Section 1931(b).

Section 1931(b)

Pregnant Minor’s Mother

$1,200

Pregnant Minor 0

Unborn 0

Total $1,200

*100% FPL Income Limit (3)

$1,591

* Example uses FPL income limits effective 12/01/12.



4. 18-YEAR OLD PREGNANT WOMAN IN HER FIRST TRIMESTER LIVING WITH HER PARENTS AND HER BOYFRIEND (FATHER OF UNBORN)

A pregnant unemployed 18 year old who is not in school, is not eligible as an “adult” for Section 1931(b) because she is not in her last trimester of pregnancy. She and her parents are then evaluated for the MI program because there is no deprivation. She is considered a “child” in the MI Program. The pregnant minor and her unborn are also in the MN MFBU with the unborn’s father to determine if he is eligible.

STEP 1: MI PROGRAM (Pregnant Minor’s MFBU)

MN PROGRAM (Unborn’s Father’s MFBU)

Pregnant Minor $1,000 Pregnant Minor (IE) $1,000

Unborn 0 Unborn 0

Pregnant Minor’s Father (IE) 3,000 Boyfriend 0

Pregnant Minor’s Mother (IE) 500 Total $1,000

Total $4,500 Maintenance Need (3) 934

Maintenance Need (4) SOC

$1,100 $3,400

SOC $66

Since the pregnant minor has a SOC in the MI MFBU, Sneede rules apply. Sneede rules also apply to the unmarried father’s MN MFBU because they are unmarried. He is eligible for MN with no SOC, as the minor mother does not allocate income to him.

STEP 2: PREGNANT MINOR’S SNEEDE DETERMINATION:

Pregnant Minor’s Father (IE) $3,000 - $600 = $2,400/2 = $1,200

Pregnant Minor’s Mother (IE) $500 -$600 = $0

MBU No.1 MBU No. 2

Pregnant Minor’s Father (IE) Pregnant Minor’s Mother (IE) (allocation from spouse)

$600 500

+ 1,200

Pregnant Minor (Senior father’s allocation)> Unborn

$1000 +1200

0

Total Sneede Maintenance Need

$2,300 $934

Total Sneede Maintenance Need

$2,200 - 750*

SOC $1,450

The minor has a SOC for MI, as she is not eligible for the 100% Program.

STEP 3: PARENTAL INCOME DISREGARD PROVISION

Pregnant Minor Unborn Unborn’s Father

$1,000 0

N/A

*The unborn is counted as a child when determining Maintenance Need amount for a pregnant mother.

Total $1000

200% FPL Limit (3) $3,182 *(FPL income limits effective 12/01/12.)



5. STEPPARENT HOUSEHOLD WITH PREGNANT MINOR AND HER BOYFRIEND (FATHER OF UNBORN)

A stepparent household includes a married couple, the husband’s separate unmarried 16-year-old pregnant minor and the unborn’s father; and, the wife’s separate child, age 10. The entire household is applying for Medi-Cal, and are first evaluated for Section 1931(b). The unborn’s father is requesting Medi-Cal, but he is ineligible for Section 1931(b) until the baby is born. Income is net non-exempt.

Example uses income limits effective 04/01/06.

STEP 1: SECTION 1931(b) MFBU

Father Stepmother Pregnant Minor Unborn Stepmother’s 10 yr. old separate child

$2,100 500 700

0 0

Total $3,300

Section 1931(b) Limit 100% FPL (5) $2,251 (ineligible)

STEP 2: SECTION 1931(b) SNEEDE DETERMINATION

Father $2,100 - $931 = $1,169/2 = $585 (allocation)

Stepmother $500 -$931 = 0 (no income allocation)

MBU 1: MBU 2: MBU 3:Father Stepmother (spouse’s allocation)

$931 $500

+ 585

Pregnant Minor (allocation) Unborn

$700 $585

+ 0

Separate Child $0

Total $2,016 Total $1,285 Total $01931 (b) Sneede (ineligible)

$1,261 1931 (b) Sneede (ineligible)

$1,261 1931 (b) Sneede (eligible)

$631

STEP 3: MN DETERMINATION (For other family members. Deprivation: absent parent)Father Stepmother Pregnant Minor Unborn

$2,100 500 700

0

NOTE: The next step is Sneede, as the pregnant minor has a SOC in the MN program; however, the pregnant minor still has a SOC due to her own income and the allocation from her father.

Total $3,300Maint. Need (4) $1,100SOC $2,200



(Example 5 - Continued)

STEP 4: SNEEDE DETERMINATIONFather $2,100 - $600 = $1,500/2 = $750 Stepmother $500 - $600 = 0 + $750 = $750

MN MBU 1: MN MBU 2:Father Stepmother (allocation)

$600 750

Pregnant Minor (allocation) Unborn

$700 750

0Total $1,350 Total $1,450Sneede Maint. Need $934 Sneede Maint. Need $750SOC $416 SOC $700

STEP 5: INCOME DISREGARD PROGRAMThe pregnant minor is NOT eligible for the full-scope 100% FPL program.

Father (IE) $2,100Stepmother (IE) N/APregnant Minor 700Unborn 0Child, age 10 (IE) + N/ATotal $2,800200% FPL Limit (5) $4,502The pregnant minor is eligible for the regular Income Disregard Program WITHOUT the “Parental Income Disregard Provision.”Note: The father of the unborn is eligible for MN with no SOC since he is under 21 and a parent of a deprived child (unborn).

His income is $200 + $700 (minor mother’s income) = $900 - $934 (Maint. Need 3) = 0



6. UNMARRIED PREGNANT WOMAN, AGE 18, HER SIBLINGS, HER MOTHER, HER UNBORN’S FATHER AND HIS SEPARATE CHILD.

The family consists of an 18 year old unmarried pregnant woman in her last trimester, and not enrolled in school; the unborn’s employed father and his separate child with income; the pregnant woman’s two siblings, ages 10 and 15; and the pregnant woman’s mother all live in the home. Income is net nonexempt.

• The unborn’s father and his separate child are receiving CalWORKs. (Not included in MFBU.)• The pregnant woman is an adult for the Section 1931(b) program, her unborn is not deprived

and she is not an essential person; thus, she is not eligible for Section 1931(b).• The pregnant woman is an ineligible member of her mother’s MFBU because her mother

requested Medi-Cal and the pregnant woman is not separately eligible for Section 1931(b).

This example uses income limits effective 12/01/12.

STEP 1: SECTION 1931(b) PROGRAM

Pregnant Woman’s Mother Child No. 1 Child No. 2 Pregnant Woman, age 18 (IE) Unborn (IE)

$1,600 0

500 3,000

0

Total $5,100

Section 1931(b) Limit 100% FPL (5) $2,251 (Over limit, Sneede rules apply.)

STEP 2: SECTION 1931(b) SNEEDE DETERMINATION

Pregnant Woman’s Mother: $1,600 - $931 = $669/3 = $223

Sneede MBU 1: Sneede MBU 2: Sneede MBU 3:Mother $931 Child No. 2 $500 Preg. Minor (IE) $3,000Child No. 1(allocation) 223 (allocation) $223 (allocation) $223Total $1,154 Total $723 Unborn (IE) 01931 (b) Sneede $1,261 1931 (b) Sneede $631 Total $3,223

1931 (b) Sneede $1261(eligible) (ineligible) (ineligible)



(Example 6 - Continued

Next, the remainder of the family is evaluated for MN. The pregnant minor, age 18, is a child in this program. The income of the senior parent (mother) is NOT included because she is eligible for Section 1931(b).

STEP 3: MN PROGRAM

Pregnant Minor Unborn Child No. 2 (sibling)

$3,000 0

500

Total $3,500


SOC $2,566

STEP 4: SNEEDE DETERMINATION

Sneede MN MBU 1: Sneede MN MBU 2:

Pregnant Minor Unborn

$3,000 0

Child No. 2 $500

Total $3000 Total $500

Maint. Need Level $750 Maint. Need Level $600

SOC $2,250 (Child 2 is MN eligible, no SOC)

Note: The pregnant minor’s mother is not in the MN MFBU; she and child 1 are eligible for Section 1931 (b) and are not included, as if they were receiving CalWORKs; therefore, each MBU has the full Maintenance Need Level.

STEP 5: 100% PROGRAM DETERMINATION (Pregnant Minor)

Pregnant Minor’s Mother (IE) $1,600

Child No. 1 (IE) N/A


Pregnant Minor 3,000

Unborn 0

Total $4,600

100% FPL (5) $2,251

(ineligible)

)




The pregnant minor is not eligible for the full-scope 100% FPL Program. Evaluate her for the Income Disregard Program using regular rules. If ineligible, evaluate her for the parental income disregard provision

STEP 6:INCOME DISREGARD PROGRAM

STEP 7: PARENTAL INCOME DISREGARD PROVISION

Pregnant Minor’s Mother (IE) $1,600 Pregnant Minor $3,000

Child No. 1 (IE) N/A Unborn 0

Child No. 2 (IE) N/A Total $3,000

Pregnant Minor 3,000 200% FPL (2) $2,522

Unborn 0 (ineligible)

Total $4,600

200% FPL (5) $4,502

The pregnant 18 year old is not eligible using the parental income disregard provision. ate her for the TLICP if other eligibility criteria are met

STEP 8:Targeted Low Income Children’s Program (TLICP)

Pregnant Minor’s Mother (IE) $1,600



Pregnant Minor 3,000

Unborn 0

Total $4,600

250% FPL (5) $5,628

The pregnant 18 year old is eligible for TLICP. She will have a premium payment of $13.00/month.



7. MARRIED PREGNANT WOMAN, AGE 19, HER HUSBAND, THEIR CHILD AND HER MOTHER

A married incapacitated pregnant woman, age 19 and her 21-year old husband are living with her mother. They also have a 3 year-old child. The 19 year-old is considered an adult in the Section 1931(b) Program; therefore, her mother is not included in the Section 1931(b) MFBU. The income is net nonexempt.

This example uses income limits effective 12/01/12.

STEP 1: SECTION 1931(b) MFBU

Pregnant Minor $750

Unborn 0

Spouse 1,800

Mutual Child 0

Total $2,550

100% FPL (4) $1,921 (ineligible)

Since the family failed the Section 1931(b) income test, evaluate the MN program.

STEP 2: MN DETERMINATION The pregnant minor’s parent is now included in this MFBU because the pregnant minor is considered a child for MN. The pregnant minor is deprived (absent father).

MN MFBU No. 1 MN MFBU No. 2

Pregnant Minor’s Parent (IE) Pregnant Minor Unborn Spouse (IE) Mutual Child (IE)

$3,000 750

0 1,800

0

Pregnant Minor (IE) Unborn Spouse Mutual Child

$750 0

1,800 0

Total $5,250 Total $2,550

Maintenance Need (5) $1,259 Maint. Need Level (4) $1,100

SOC $3,991 SOC $1,450

MN MFBU No. 3

Pregnant Minor’s Parent (IE) Pregnant Minor (19) Unborn

$3,000 750

0

NOTE: Sneede rules apply to MFBU 3 because the minor’s parent has a SOC and the minor has income. If the parent keeps her personal needs allowance of $600 and allocates the remainder to her daughter, the parent would be eligible for MN with no SOC.

Total $3,750

Maint. Need Level (3) $934

SOC $2,816




36.2.12 Notices of Action

Approvals

Approval Notices for this program are generated by CalWIN.

STEP 3: EVALUATE FPL PROGRAMS (for pregnant minor and her child)

Income Disregard Program 133% Program

Pregnant Minor’s Parent (IE) Pregnant Minor Unborn Spouse (IE) Mutual Child (IE)

$3,000 750

0 1,800

0

Pregnant Minor (IE) Unborn Spouse Mutual Child

$750 0

1,800 0

Total $5,550 Total $2,550

200% FPL (5) $4,502 133% FPL (4) $2,555

ineligible eligible

The mutual child is eligible for the 133% program. The pregnant woman is not eligible for the Income Disregard program for her pregnancy-related services using regular Medi-Cal rules. Evaluate her using parental income disregard rules.

STEP 4: Parental Income Disregard Provision

Pregnant Minor Unborn Spouse (IE) Mutual Child (IE)

$750 0

1,800 0

Total $2,550

200% FPL (4) $3,842

The pregnant minor is eligible for the parental income disregard provision; however, she has a SOC of $3,991 for her other services.

NOTE: Since no income from the pregnant minor’s parent(s) is counted, if the pregnant minor’s parent applies for her and provides the necessary information about the minor but refuses to provide income information, the EW may make the determination without it. This sometimes occurs when the minor is married and living in the home of the senior parent because the parent considers the child an adult.

EWs may by-pass the regular Income Disregard Program rules and determine eligibility using the parental income disregard provision first unless it would be more beneficial to use the regular rules e.g., the pregnant minor or her boyfriend/spouse have income, her parents have little income, or there are siblings in the home, which increases the family size and income limit as in Example 5.



Discontinuances

An adequate and timely 10-day notice is required when discontinuing persons from the Income Disregard Program.

Send a discontinuance NOA when:

• The infant turns age one (unless the baby was hospitalized before age one and remains in the hospital). The EW will receive MEDS alert '9526'.

• At the end of pregnancy.

• Issue a NOA at the beginning of the 60-day postpartum period, as it informs the woman about her entitlement to postpartum care.

• Set a case alert to discontinue her at the end of the 60-day postpartum period. A second discontinuance notice is not required.

Discontinuance of Income Disregard & Another Program

When discontinuing the Income Disregard Program and benefits under another Medi-Cal Program, a separate Income Disregard NOA is not required. Simply add the statement “Your benefits under the Income Disregard Program are also stopping”. For example, when the entire case is being discontinued due to loss of residency, only one discontinuance notice is required.

• A woman who is eligible for the Income Disregard Program during the month pregnancy ends receives 60-day postpartum benefits under the same Aid Code, without regard to any changes except residency.

• Many persons will remain eligible under the Income Disregard Program even though their family income changes or they have excess resources. [Refer to “Property Waiver Program,” page 36-40, and “Continued Eligibility for Pregnant Women, Infants, and Children [50262.3],” page 22-1.]

Denials

CalWIN generates a denial NOA when a pregnant woman and/or infant is not eligible due to income in excess of 200% of FPL, unless Continued Eligibility/Deemed Eligibility rules apply. Workers must delete this denial NOA and establish eligibility under, MN or MI with a share of cost for the pregnant woman, and TLICP for the infant if other eligibility criteria are met.



36.2.13 Minor Consent

A pregnant minor may be eligible for no SOC Medi-Cal under the Income Disregard Program using regular MFBU rules; or, by applying the “Parental Income Disregard Provision”. She may also choose to apply for the Minor Consent program. It is important to carefully evaluate the circumstances of the minor and her family to determine:

• Is the minor in need of confidential services• Who has income in the family• Who needs Medi-Cal and do they have linkage, and• Is the minor mother eligible for full-scope no SOC Medi-Cal under another

program.

A pregnant Minor Consent applicant is eligible under the Income Disregard Program when she would have a share of cost and her income is at or below 200% of the FPL. Aid Code 7N is a federally funded Aid Code for this service specific program which allows appropriate tracking. A pregnant minor consent applicant is eligible under Aid Code 7N as long as her income is at or below 200% of FPL.

• Do not use Income Disregard Aid Code 44 for a pregnant minor.

• A minor of any age who is requesting pregnancy-related services must be assigned Aid code 7N.

• Aid Code 7N covers pregnancy-related services only and always has no SOC.

36.2.14 Hospitalized Infants

Infants who are otherwise eligible and who are receiving inpatient medical services for a continuous period, beginning before and continuing beyond their first birthday, will remain eligible for this program until the end of the continuous stay.

MEDS automatically terminates the baby's Income Disregard Program record at the end of the 13th month; therefore, to issue these special benefits the EW must:

• Complete an SC 1296 requesting the MTO to reactivate the baby online, using the special “exception eligible” ESAC of “4” or “9”.

• Advise the client to report any change in the child's status within 10 days.

MEDS will terminate the child's record. If the child is reactivated, an alert will be generated by MEDS every six months to remind the EW to check on the child's status. The EW must reactivate the child's MEDS record if still hospitalized.



Determine if the child might meet permanent disability criteria as ABD-MN.

Eligibility cannot be established for the Income Disregard Program for a child who is beyond age one when there has been a break in eligibility for any reason, even though there has been no change in the infant's inpatient status.[Refer to User’s Guide to State Systems Handbook, “9526 - Infant/Child Elig Terminated - Check for Exception Elig - Action,” page 11-62 for complete instructions.]

36.2.15 Midyear Status Report (MSR)

Midyear Status Report

Pregnant women, whose ONLY basis for eligibility is based on pregnancy; and children under age 21, are exempt from the Midyear Status Report (MSR) requirement.

Social Security COLA Disregard

The COLA increase in Social Security benefits received in January is to be disregarded for ALL FEDERAL POVERTY LEVEL PROGRAMS (including the TLICP, 200% Income Disregard, 100%, 133%, and Property Waiver programs) from January through March of each year, if applying the increase makes the person ineligible for those programs.



36.3 133% Program for Children Ages One Through Five

36.3.1 Definition

The 133% Program provides Medi-Cal with no share of cost to certain otherwise eligible children ages one through age five.

To qualify under this program, the net nonexempt family income must be over the maintenance need but below 133% of the Federal Poverty Level (FPL). [Refer to Chart Book, “Federal Poverty Level Programs 2016 Monthly Income Comparison Chart,” page 5-11.] & [Refer to “Property Waiver Program Criteria,” page 36-41 for the Property Waiver Provision of the 133% Program.]

• Cases with a share of cost (SOC) are potentially eligible for the 133% Program.

• Only applicable AFDC-MN/MI deductions are allowed.

• Private health insurance premiums are not deducted when determining if the family income is under the federal poverty level.

• If the family income is less than the Maintenance Need or more than 133% of the federal poverty level, there is no eligibility for the 133% Programs. (Evaluate eligibility under the Targeted Low Income Children’s Program (TLICP). Issue Medi-Cal under the appropriate AFDC-MN or MI program if there is no eligibility for the TLICP.)

36.3.2 Application for the 133% Program

Intake

The 133% Program does not require a separate application.

• Eligibility for this program is determined as part of the MN/MI application. The 133% Program cannot be established earlier than April 1, 1990.

• Retroactive eligibility can be established for the 133% Program, however, not for months prior to April 1, 1990.



• A 133% Program must be denied and the denial NOA deleted when child(ren) ages one through five are ineligible due to income in excess of 133% of the FPL.

Note:Children whose family income exceeds 133% of the FPL will receive Medi-Cal under the TLICP, or as AFDC-MN or MI with a share of cost, if otherwise eligible. The notice advises the parent/caretaker relative that the child(ren) were considered for eligibility under the 133% Program.

Continuing Cases

• Persons who are found eligible cannot be approved earlier than April 1, 1990.


• Eligibility for the 133% Program can begin no earlier than age one.

Note:A child can continue to receive benefits under the Income Disregard Program if he/she was receiving inpatient care for a continuous period which began before and continues beyond his/her first birthday.

• Eligibility can continue, depending on family income, until the end of the month in which the child reaches age 6.

Exception:Eligibility for the 133% Program can be continued after age six if the child is receiving inpatient services for a continuous period which began before and continues beyond the child's sixth birthday.

• Eligibility can be established retroactively, but not prior to 4/1/90.

Note:State MEDS programming is in place which will generate an EW alert message (CEWA) in the month prior to the child's sixth birthday.



36.3.4 Scope of Benefits

There are two groups of children under the 133% Program:

36.3.5 Eligibility Determination

Note:Rules pertaining to the treatment of income have not been changed by these programs. Apply the usual income determination procedures as appropriate; (e.g., conversion of weekly or biweekly income to monthly, average fluctuating income, prospective budgeting, etc.).


72 Citizen/lawful permanent resident/PRUCOL/Conditional Status. (full scope benefits).

74 Undocumented status/temporary visa (OBRA) (emergency medical services only).

Step Procedure

1 Determine the child(ren)'s eligibility under Section 1931(b) or the AFDC-MN/MI Program.

2 Determine eligibility for FPL programs using regular rules or using Sneede rules if the MFBU includes a Sneede member, when a case has BOTH:

• A share of cost, and

• A child ages 1 through 5.

3 Include all family members in the MFBU (eligible and ineligible persons) when determining the Maintenance Need and Poverty Level amounts. (Do not count excluded persons or PA recipients.)

4 Allow only AFDC-MN/MI deductions when computing the family’s net nonexempt income for the 100/133/200% Programs.

EXCEPTIONS: Health insurance premiums are not an allowable deduction. If the MFBU includes an ABD-MN person, allow only AFDC-MN/MI deductions for the 133% Program. ABD-MN deductions are not allowed.

5 Repeat theses steps if income changes and/or new information is received which affects the SOC or children eligible for the program.



36.3.6 Approvals and Denials

Use this chart to determine the appropriate Approval/Denial actions. These rules apply to both new applications and continuing cases.

Note:The COLA increase in Social Security benefits which is received in January is to be disregarded for ALL FEDERAL POVERTY LEVEL PROGRAMS (including Income Disregard, 100%, 133%, TLICP and Property Waiver programs) from January through March, if applying the increase will make the person ineligible for those programs.

IF net nonexempt income of the MFBU is: THEN:...

At or below Maintenance Need Approve under the regular AFDC-MN/MI program.(May qualify for Property Waiver)

Between Maintenance need and 133% of FPL Approve eligible child(ren) under the 133% Program with no SOC.

Over 133% of FPL but less than 250% of FPL Record 133% Program denial and delete the 133% denial NOA. Approve TLICP with or without premium payment.

Over 250% of FPL Record TLICP denial and delete the denial NOA. Approve AFDC-MN/MI with a share of cost.




1. A 133% eligible child will receive benefits under the no cost 133% Program, either full-scope or restricted to emergency care.

2. Include 133% eligible children in the MFBU of other eligible MN/MI family members.

3. When discontinuing a child from the 133% Program because he/she has turned age six, evaluate eligibility for the 100% FPL Program and/or TLICP. CEC rules apply if the child does not qualify for the 100% FPL program or TLCIP without premium.

MFBU Example:

A married couple (both age 25) are applying for Medi-Cal because the mother is pregnant. They have two other children: a boy age 7, and a girl age 4. They have no private health insurance and the husband is fully employed with net non-exempt earnings of $2,000.

Example uses FPL levels effective 12/1/12.

MFBU = 5


133% of FPL $2,994

100% of FPL $2,251

150% of FPL $3,377

250%of FPL $5,628

133% Program MFBU MI MFBU (5)

Child, Age 4 Pregnant Woman (eligible for non-pregnancy related care with SOC, Aid Code 87)

100% Program MFBU Child, Age 7

200% Income Disregard MFBU Spouse (IE)

Pregnant Woman Unborn

Unborn Child, Age 7 (IE)

Child, Age 4 (IE)



All other eligibility factors remaining the same:

• Child, age 4, will receive no-SOC Medi-Cal under the 133% Program until she reaches age 6. She will then be transferred to the TLICP.

• Child, age 7, will receive no-SOC Medi-Cal under the 100% Program.

• When the baby is born, the otherwise eligible newborn is deemed eligible for the 200% Income Disregard Program. The mother is no longer eligible for Medi-Cal after her 60-day postpartum period ends (no deprivation). Her postpartum benefits are issued under the 200% Income Disregard Program Aid Code.

36.3.8 Notice of Action Requirements

Approval of Benefits

An approval notice for the 133% Program must be issued when establishing eligibility for that program.

Discontinuance of 133% Benefits Only

A timely 10-day notice of action is required when discontinuing persons from the 133% Program due to either of the following reasons:

• Increased income.• A child reaches age six. (Determine eligibility for the 100% Program or

TLICP.)

36.4 100% Program


The 100% Program provides no share of cost (SOC) Medi-Cal benefits to otherwise eligible children who meet the following criteria:

• Have attained age 6, AND• Whose family income is over the Maintenance Need but below 100% of Federal

Poverty Level (FPL). [Refer to Chart Book, “Federal Poverty Level Programs 2016 Monthly Income Comparison Chart,” page 5-11.] [Refer to “Property



Waiver Program Criteria,” page 36-41 for the Property Waiver Provision of the 100% Program]

For this program, a person under age 19 is a considered a child.

Exception:A fourteen to nineteen year old who does not live with a parent or caretaker relative and is defined as an adult IS CONSIDERED A CHILD FOR THIS PROGRAM and is eligible for the 100% Program. If he/she is the only family member, his/her income is compared to the 100% of FPL amount for one.

Children who meet the above criteria are eligible, depending on family income, until the end of the month in which the child reaches age nineteen.

36.4.2 Effective Date

Because of necessary systems changes, the actual implementation date of this program is 11/1/91. However, OBRA '90 requires states to provide benefits to eligible children as of 7/1/91.

Eligible children are entitled to a reimbursement if they have met all or part of the share of cost. [Refer to “Change in the Share of Cost (SOC),” page 62-3.]


Eligibility can begin no earlier than age 6.

• Children ages 1 - 5 must have their eligibility determined under the 133% Program if they have a share of cost.

Eligibility continues, depending on family income, until the end of the month in which the child reaches age 19.

Note:If an individual in the 100% Program becomes pregnant and has no increases in income, the income disregard (200%), program does not apply, because the 100% program provides full scope benefits including pregnancy related and postpartum benefits with no share of cost.

Exception:Eligibility for the 100% Program can be continued after age 18 if the child is receiving inpatient services for a continuous period which begins before and continues beyond his/her 18th birthday.



Eligibility can be established retroactively, but not prior to 7/1/91.


There are two groups of children eligible for this program:

36.4.5 Eligibility Determination

Follow these steps to determine a child's eligibility for the 100% Program:


7A Citizen, permanent resident, PRUCOL, or conditional resident. (Full Scope)

7C Undocumented or temporary visa, (OBRA). Restricted to emergency care and pregnancy services.

Step Procedure

1 Determine the child(ren)'s eligibility under Section 1931(b) or the AFDC-MN/MI Program.

2 The 100/133/200% Programs Worksheet, (SC 1560) or MC 175-5 may be completed if the MFBU includes a Sneede class member, when a case has BOTH:

• A share of cost, and

• A child age 6 through 18.

3 Include all family members in the MFBU (eligible and ineligible persons) when determining the Maintenance Need and Poverty Level. (Do not count excluded persons or PA recipients.)

4 Allow only AFDC-MN/MI deductions when computing the net nonexempt family income for the 100% Program.

EXCEPTIONS: Health insurance premiums are not an allowable deduction. Also, if the MFBU includes an ABD-MN person, complete an MC 176-M using only AFDC-MN/MI deductions for the 100% Program.

5 Repeat these steps if income changes and/or new information is received which affects the share of cost or children eligible.



36.4.6 Approvals & Denials

Use this chart to determine the appropriate Approval/Denial actions. These rules apply both to new applications and continuing cases.


• A 100% eligible child will receive eligibility under the 100% Program, either full-scope or restricted to emergency care.

• Include 100% eligible children in the Maintenance Need with other eligible AFDC-MN/MI family members.Discontinuance

• When discontinuing a child from the 100% FPL program because he/she has turned age 19, evaluate for AFDC/MN-MI.

Note:CEC rules apply if the child would have a SOC

Note:The COLA increase in Social Security benefits which is received in January is to be disregarded for ALL FEDERAL POVERTY LEVEL PROGRAMS (including Income Disregard, 100%, 133%, TLICP and Property Waiver programs) from January through March, if applying the increase will make the person ineligible for those programs.

36.4.8 Notice of Action Requirements

Approval of Benefits

An approval notice for the 100% Program must be issued when establishing eligibility for that program.

IF net nonexempt income of the MFBU is: THEN:...

At or below Maintenance Need Approve under the regular AFDC-MN/MI program.(May qualify for Property Waiver)

Between Maintenance need and 100% of FPL Approve eligible child(ren) under the 100% Program.

Over 100% of FPL Record 100% Program denial. Delete the denial NOA. Approve the TLICP or AFDC-MN/MI with a share of cost.



Discontinuance of 100% Benefits Only

An adequate and timely 10-day notice of action is required when discontinuing persons from the 100% Program due to either of the following reasons:

• Increased income.• A child reaches age 19. (Determine eligibility for AFDC-MN/MI programs.)

Note:CEC rules apply if the child is not eligible for the 100% FPL program and is found ineligible for the TLICP without the premium payment.



36.5 Property Waiver Program

36.5.1 Background

The California State Legislature passed Assembly Bill (AB) 99 which provided that pregnant women and infants up to age one whose family income is between 186% and 200% of the federal poverty level (FPL), but whose family assets exceed the Medi-Cal property limit, may qualify for Medi-Cal under the Property Waiver Program. This program became effective January 1, 1992, and was originally called the Asset Waiver Program.

Effective September 1, 1994, the Property Waiver Program, formerly known as the Asset Waiver program, became available to pregnant women and infants up to age one with family income at or below 200% of FPL. This change is due to the passage of AB 2377 signed by Governor Wilson on July 9, 1994.

Effective July 1, 1995, the need to verify property for this program was eliminated. No property verification is required for any property listed on the MC 210 when it is determined that the applicant is requesting pregnancy related services (or full scope services for an infant), and the family income is at or below 200% of the FPL. In addition the applicant is not required to complete supplemental property forms.

Senate Bill 903 and Assembly Bill 217 amend Section 14148.75 of the Welfare and Institutions Code to waive the property limit for all children in the Percent Programs effective March 1, 1998. The Property Waiver Program now applies to:

• Pregnant women and infants up to age one with family income at or below 200% of the FPL,

• Children ages one to six with a family income at or below 133% of the FPL, and• Children ages six to nineteen with a family income at or below 100% of the FPL.

Note:Any pregnant woman and/or child under 19 years with family net nonexempt income at or below the FPL for his/her applicable Income Disregard/Percent Program is potentially eligible for the Property Waiver Program.



36.5.2 Property Waiver Program Criteria

Pregnant Women and Infants

In order to qualify for the Property Waiver Provision of the Income Disregard Program, the following criteria must be met by pregnant women and infants:

• Family income must be at or below 200% of the Federal Poverty Level (FPL), and

• The family must have property, and

• The pregnant woman is made aware of the choice between restricted and full scope options, and chooses restricted scope of benefits for herself (and/or full scope for an infant), and

• The applicant (pregnant woman) does not want to verify property and/or spenddown any excess property in order to qualify for full-scope coverage for herself or to establish Medi-Cal eligibility for other family members.

• The pregnant woman and/or infant are otherwise eligible for Medi-Cal.

OTHER FAMILY MEMBERS ARE INELIGIBLE UNLESS PROPERTY IS VERIFIED AND, IF OVER THE PROPERTY LIMIT, REDUCED TO THE MEDI-CAL LIMIT.

Children One to Six Years

In order to qualify for the Property Waiver Provision of the 133% Program, the following criteria must be met by children who are at least one year of age but under six years of age:



• The applicant does not want to verify property and/or spenddown any excess property in order to establish Medi-Cal eligibility for other family members.

• The child is otherwise eligible for Medi-Cal.




Children Six to Nineteen

In order to qualify for the Property Waiver Provision of the 100% program, the following criteria must be met by children who are at least six years but under nineteen years of age:



• The applicant does not want to verify property and/or spenddown any excess property in order to establish Medi-Cal eligibility for other family members.

• The child is otherwise eligible for Medi-Cal.


36.5.3 Scope of Coverage

Under the Property Waiver Program:

• Pregnant women are eligible for Medi-Cal coverage ONLY for their pregnancy-related services. They are NOT “dually” eligible for full scope Medi-Cal with a share of cost as they can be in the Income Disregard Program.

• Infants up to one year old receive either:

• Full-scope Medi-Cal benefits, or• If undocumented, emergency services only.

• Children ages one to six with a family income at or below 133% of the FPL, and children ages six to nineteen with a family income at or below 100% of the FPL receive either:

• Full-scope Medi-Cal benefits, or• If undocumented, emergency services only.




36.5.4 Property Verification Not Required

The family must answer all questions on the “Statement of Facts” (MC 210). No property verification is required for any property listed on the MC 210 (unless the property produces income) whenever the EW determines that:

• The applicant/recipient is only requesting pregnancy related services (and/or full scope services for an infant), and the EW has determined that the family income is at or below 200% of FPL, and/or

• The applicant/recipient is only requesting services for a child, and the EW has determined that the family income is at or below 100% or 133% of the FPL for the appropriate Percent Program for that child.

Note:The applicant is not required to complete any supplemental property forms.

36.5.5 Income Generated From Waived Property

Income generated from property whose value is waived under the Property Waiver Program must be counted when determining the family’s share of cost/and or eligibility for the Property Waiver program. This income must be counted in all cases except if it is unavailable, exempted by specific court order or statute, etc.

The EW must document in Maintain Case Comments whenever a case has income generated from property which is exempt.

Although the family must answer all questions on the MC 210, verification of property is not required if the family is applying under the Property Waiver Program. However, in those situations where the EW becomes aware that the family’s property is producing income, the client MUST PROVIDE VERIFICATION OF THE INCOME. The verification may include information normally used to verify property.

Rental Income from Real Property

If the client has earned or unearned rental income from real property the EW must give the family an opportunity to verify any expenses associated with the rental income by having the client complete and verify those questions on the MC 210 PS that specifically pertain to rental expenses. The Property Waiver client is not required to provide any verification of the property other than what is necessary to establish the amount of income and any associated expenses.



Note:If the applicant has other real property and would be over the property limit even if the utilization requirement was met, the applicant is not required to submit proof of utilization.

36.5.6 Determining Eligibility for Property Waiver

Pregnant Woman and/or a Child Under One

Follow these steps to determine eligibility for the Property Waiver Program when a household includes a pregnant woman and/or a child under age one:

Step Action

1 Determine if income is at or below 200% of the FPL using regular FPL rules, or under Sneede rules if the MFBU includes a Sneede class member. If yes, proceed to step 2. If no, stop here.

2 If the criterion in step 1 is met, inform the client of the choice to either:

• Receive full scope benefits for herself and other family members and provide property verification and spenddown any excess property to meet the regular Medi-Cal eligibility requirements. Explain full scope benefits and the spenddown process.

OR

• Receive restricted benefits under the Property Waiver Program and choose not to verify and/or spenddown any excess property.

3 Explain the following to the applicant:

• If there is excess property, the amount of excess property and how it can be spent down or converted to “exempt” property, and

• What benefits the family will be eligible for if assets are spent down, and

• What benefits are available to the pregnant woman and her baby if the family chooses to retain their assets and receive restricted benefits only.

4 Determine that all other eligibility factors are met.



Children ages one to six with family income at or below 133% of the FPL, and children ages six to nineteen with family income at or below 100% of FPL (No pregnant woman)

Follow these steps to determine eligibility for the Property Waiver Provision of the 100% and 133% Programs when a household includes Percent Program children:

Zero Share-of-Cost and Property Waiver

If a child or pregnant woman is otherwise eligible for zero share-of-cost Medi-Cal under the Medically Needy (MN) or Medically Indigent (MI) program, (Aid codes 34, 82 or 86) but has excess property and chooses not to verify property, Section 6 of Mail-In application is not completed, approve these individuals using the appropriate Income Disregard/Percent Program Aid Code to identify them as Property Waiver cases.

Note:The EW must not set up anyone on an FPL Program if they are eligible for regular zero share-of-cost Medi-Cal.

Step Action

1 Determine eligibility if family income is at or below 100% or 133% of the FPL under regular rules or Sneede rules if the MFBU includes a Sneede class member. If yes, proceed to step 2. If no, stop here.

2 If the criterion in step 1 is met, inform the customer of the choice to either:

• Receive full scope benefits for herself and other family members and provide property verification and spenddown any excess property to meet the regular Medi-Cal eligibility requirements. Explain full scope benefits and the spenddown process.

OR

• Receive Medi-Cal benefits under the Property Waiver Program or TLICP for the children only and choose not to verify and/or spenddown any excess property.

3 Explain the following to the applicant:

• If there is excess property, the amount of excess property and how it can be spent down or converted to “exempt” property, and

• What benefits the family will be eligible for if assets are spent down, and

• What benefits are available to the children if the family chooses to retain their assets and receive benefits for the children only.

4 Determine that all other eligibility factors are met.



36.5.7 Denials

Deny Medi-Cal benefits for the Property Waiver Program if a Medi-Cal applicant’s family has income over 200% of FPL for pregnant women or infants.

Deny Medi-Cal benefits for the Property Waiver Program if a Medi-Cal applicant’s family has income over 133% of FPL for children ages one to six or 100% of FPL for children ages six to nineteen. (Eligibility for other Medi-Cal must be evaluated.)

Note:Delete the FPL denial NOAs.

36.5.8 Discontinuance

A special discontinuance NOA must be used when terminating benefits under the Property Waiver program. Benefits must be discontinued for:

• The pregnant woman, at the end of her 60 day postpartum period. (Set a case alert to flag this date.)

• The infant, at the end of the month that the child turns one.

• The child in the 133% program, at the end of the month that the child turns six.

• The child in the 100% Program at the end of the month that the child turns nineteen.

Note:When discontinuing an infant or child from an FPL Property Waiver Program, the EW must evaluate the child’s eligibility for the other FPL Programs

• If he/she is not eligible for the other FPL programs, then the EW must evaluate the child’s eligibility for share of cost AFDC-MN/MI Medi-Cal.



36.5.9 Property Changes

When a pregnant woman, infant or child is income eligible for one of the FPL programs, but becomes property ineligible while receiving Medi-Cal benefits under other than an FPL program and chooses not to verify and spenddown property, the EW should take the following action:

36.5.10 Income Increases

Pregnant women and Infants are exempt

Once eligibility for the Property Waiver Provision of the Income Disregard Program has been established, increases in family income are to be disregarded for pregnant women and infants due to Continued Eligibility (CE)/Deemed Eligibility (DE) rules. These are the only Property Waiver eligibles who are NOT affected by increases in family income.

36.5.11 Examples

Pregnant Woman with an Absent Parent

Shirley is pregnant and is applying for Medi-Cal. She has $1000 in her savings account. She is presently working, and the EW determines that her net nonexempt income is below 200% of the federal poverty level. The EW explains that she has a choice to EITHER provide verification of the value of the property, OR not verify her property and receive benefits under the property waiver program. Shirley decides she wants only pregnancy-related services under the Property Waiver program. Do not verify her property. (The EW must have her sign the “Informal Application Refusal” (SC166) for full scope benefits).

Two months later, Shirley reports that she is now receiving DIB. Although Shirley now has less income, she still chooses to receive pregnancy-related benefits only under the property waiver program. She remains eligible under the Property Waiver

Step Action

1 Discontinue all family members from regular Medi-Cal benefits (including the pregnant woman for her non-pregnancy care).

2 If family income is at or below the FPL limit for the appropriate FPL Program, the pregnant woman and/or infant/child(ren) remain in active status and change their Aid Codes to the appropriate FPL Aid Code effective the first of the following month, and

3 Send appropriate approval NOA



Program through her postpartum period. Her baby will also be eligible under the Property Waiver Provision of the Income Disregard (200%) Program until age one and possibly eligible under the Property Waiver Provision of the 133% Program, 100% Program or TLICP until the end of the month in which the child reaches age nineteen.

Should she decide that she would like to have full scope Medi-Cal at a later date, she must verify her property and if it is within the property limit, then Property Waiver program benefits would be discontinued and she would be eligible under the regular Medi-Cal Program, AFDC-MN.

Unmarried Couple with an Unborn

Becky is pregnant and she is living with the baby's father, Jim. They are not married. Jim, age 19, is potentially eligible for Medi-Cal. He is employed full-time, and does not wish to apply. His income and property are not counted to the MFBU.

Becky's net nonexempt income is approximately 190% of the FPL. However, she has full access to a joint checking account with Jim, in which they both deposit money to cover household expenses, current balance $2,000. She also has separate nonexempt assets that equal $3,000. Therefore, she is over the Medi-Cal property limit. She is not required to verify any property and may choose to receive no-share-of-cost pregnancy benefits only under the Property Waiver program.

The EW must explain to Becky that if she verifies and reduces her assets she will qualify for full-scope Medi-Cal with a share of cost for her non-pregnancy related care. Also, that the full balance of their joint account is considered as her property. She may remove her name from their joint account, and transfer 1/2 of the balance to her separate account. (She must provide evidence if she claims that less than 1/2 of their joint account belongs to her.)

Becky chooses to have only pregnancy benefits. Later, she quits her job and she only receives income-in-kind (she is now within the Maintenance Need Level). Since she still has not verified or spent down her property, she remains eligible for the Property Waiver Program. She must be informed of her option to choose full scope benefits with no share of cost. She would have to spenddown and verify her property in order to be eligible for regular Medi-Cal with no share of cost.

Married Couple with Mutual Children, Continuing Case

A married pregnant woman and her 8-month-old son are currently eligible for the Income Disregard Program (February) with net nonexempt family income below 200% of FPL. Her husband is fully employed and is ineligible for benefits. In April, mom reports that she has lottery winnings of $50,000.



The EW must explain that she must spend down her excess property in order to remain eligible for full-scope coverage. Or, that she can keep the money and still remain eligible for the Property Waiver program.

Under the Property Waiver Program:

• She remains eligible for no-share-of-cost pregnancy-related services through her 60-day postpartum period.

• Her son, now 10 months old, remains eligible for full-scope benefits until the end of the month in which he reaches his first birthday and is then evaluated for the Property Waiver provision of the 133% Program or the TLICP.

• The newborn baby is also eligible for full-scope benefits until age one and is then evaluated for the Property Waiver provision of the 133% Program or the TLICP.

Mom chooses to keep the money. Her full-scope coverage (for non-pregnancy care) with a share of cost must be discontinued with a 10 day notice of action. A Property Waiver approval notice of action must also be sent to her.

Unmarried Mother Applicant With Two Children

An unmarried woman is applying for herself and her two children, ages, 12 and 15. She works part time and the EW determines that her net nonexempt income is below 100% of the FPL. She has a a savings account valued at $10,000 for her children’s future education. The father of both children is absent. The EW notifies the woman that she has excess property. She must either verify and spendown to the Medi-Cal limits if she wants to be included for Medi-Cal eligibility or if she chooses not to verify and spendown the property, she can receive Medi-Cal for the children only under the Property Waiver provision of the 100% Program. She chooses to retain her property and receive Medi-Cal for the children only under the Property Waiver Provision. The EW must deny regular Medi-Cal for the mother for excess property and approve the Property Waiver Program for the children.

36.6 Optional Targeted Low-Income Children’s Program

The enactment of the Assembly Bill (AB) 1494 (Chapter 28, Statutes of 2012) transitioned children from the Healthy Families Program (HFP) to Medi-Cal. These children are now covered under the optional targeted low-income coverage group,



pursuant to the federal Social Security Act, §1902 (a)(10)(ii)(XIV). This new coverage group is named the Optional Targeted Low-Income Children’s Program (OTLIC).

OTLIC increased income eligibility for children zero to 19 years of age to 266% of the Federal Poverty Level (FPL) with the implementation of the Affordable Care Act (ACA). The OTLIC program under ACA is considered Modified Adjusted Gross Income (MAGI) MC.


OTLIC provides MC with or without premium payment to certain otherwise eligible children ages zero through age 19.

• To qualify under this program, the net non-exempt family income must be at or below 266% of the FPL. [Refer to Common-Place Handbook, “Targeted Low-Income Children’s Program (TLICP) and 250% Working Disabled Program (WDP),” page 5-17.] &

• OTLIC is an asset waiver program. Property is not considered, nor verified.

36.6.2 Application for the OTLIC

OTLIC does not require a separate application.

Eligibility for this program is determined as part of the MC application.

OTLIC aid codes cannot be granted before January 1, 2014.


There are two groups of children under the OTLIC:

1. Children eligible for OTLIC MC WITHOUT a premium payment and,



2. Children eligible for OTLIC WITH a premium payment.

TLICP WITHOUT Premium Payment


T2 MAGI TLCIP - Children 6-19 Not Subject to Premium

Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; ages 6 through the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday for family income above 133% up to and including 160% of the FPL.

T4 MAGI TLICP - Children 1-6 Not Subject to Premium

Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; ages 1 through the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday and family income is above142%of FPL and up to and including 160% of FPL.

T5 MAGI TLICP - infants Not Subject to Premium

Provides full scope, no-cost Medi-Cal for infants who are U.S. citizens, have satisfactory immigration status, or awaiting citizenship verification.

Coverage is up to the month of their first birthday or continues beyond one year when in an inpatient status that began before the first birthday. Family income is above 208% and up to and including 266% of the FPL.

T7 MAGI TLCIP - Children 6-19 Not Subject to Premium

Provides restricted, no-cost Medi-Cal coverage to children with unsatisfactory immigration status; ages 6 through the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday for family income above 133% up to and including 160% of the FPL.

T9 MAGI TLICP - Children 1-6 Not Subject to Premium

Provides restricted, no-cost Medi-Cal coverage to children with unsatisfactory immigration status; ages 1 through the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday and family income is above142%of FPL and up to and including 160% of FPL.

T0 MAGI TLICP - infants Not Subject to Premium

Provides restricted no-cost Medi-Cal for infants who have unsatisfactory immigration status.

Coverage is up to the month of their first birthday or continues beyond one year when in an inpatient status that began before the first birthday. Family income is above 208% and up to and including 266% of the FPL.



36.6.4 Premiums

Monthly premiums amounts are set up at thirteen dollars ($13) per child with a maximum family contribution of thirty-nine dollars ($39) per month (i.e. $13 per month/one child,$26 per month/two children, and $39 per month/for three or more children).

Note:These premiums are not allowed as a deduction against income for members of the MC family budget unit.

TLICP WITH Premium Payment


T1 MAGI TLCIP - Children 6-19 Subject to Premium

Provides full-scope coverage based on a premium payment to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; from age 6 to the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday, with family income above 160% up to and including 266% of the FPL.


Provides full-scope coverage based on a premium payment to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; from age 1 to the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday, with family income above 160% up to and including 266% of the FPL.


Provides restricted coverage based on a premium payment to children with unsatisfactory immigration status; from age 6 to the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday, with family income above 160% up to and including 266% of the FPL.


Provides restricted based on a premium payment to children with unsatisfactory immigration status; from age 1 to the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday, with family income above 160% up to and including 266% of the FPL.



Premium Collection

When the EW processes an application, or completes an annual redetermination and determines the family income is above 160% of the FPL, a notification will be made to MAXIMUS for collection of the premium. Premium payment aid codes (T1, T3, T6, and T8) reported to MEDS will be then reported to MAXIMUS

Cases with family income up to 160% of the FPL will not be subject to premiums and information for these children will not be sent to MAXIMUS.

The name “MAXIMUS” will not be used on any materials going to clients. If a client has a question about the premium payment, the client is to be directed to contact the “Medi-Cal Premium Payment Section” at 1-800-880-5305. This contact information will be noted on their premium informing materials and billing statements.

Missed Payments

When a client misses a premium payment for thirty (30) calendar days, the Medi-Cal Premium Payment Section will send an overdue reminder notice to the family regarding payment due (monthly billing statement). The notice and billing statement specifies the amount past due, payment date, and potential discontinuance language for non-payment of premiums. If the client does not make a payment on the past due amount within an additional fifteen (15) calendar days, the Medi-Cal Premium Payment Section sends an additional reminder notice. Any collected past due premiums will first be applied to the outstanding balance owed.

Example:If a family pays $26 dollars per month in premiums, has a balance due of $78 to cover three months in arrears, and they pay $52, the $52 will be applied to the two most outstanding months.

The Medi-Cal Premium Payment Section will also contact the client by telephone to remind the client of the imminent disenrollment.



36.6.5 Non-Payment of Premium Process

A non-payment of premium (NPP) condition occurs when the beneficiary is two payments past due on premiums. The Medi-Cal Premium Payment Section will notify the county when the beneficiary has not paid premiums for 60 days and there was no response to the non-payment notices from the client. When this information is received, the following process occurs for clients on premium aid codes:

Step Who Action

1. Maximus • Identifies clients in non-payment status on the 15th of each month and develops the NPP list.

• Sends the NPP list by the 18th of each month to CalWIN.

2. CalWIN Project Distributes the NPP list to each county by the 25th of the month.

3. Program Receives the list from the CalWIN Project and distributed to the District Offices.

4. EW • Completes an Ex Parte review to determine if the client is eligible for a non-premium aid code.

• (If no other eligibility exists), takes action to discontinue the clients identified in the NPP list. - Issues adequate and timely NOA to terminate eligibility.

- Ensure termination of eligibility in MEDS for clients in non-payment status with an EW40 MEDS transaction and termination reason G1.

[Refer to “CalWIN Process,” page 36-56 for steps on discontinuing the individual in CalWIN.]

Note: MAXIMUS will continue to bill the client each month and also includes the client on the NPP list in each subsequent month until the client resolves the non-payment condition or MEDS indicates the client is no longer active in the premium aid code.

5. Client To prevent discontinuance, a client must pay past due premiums prior to the discontinuance date. The client may do this by contacting the Medi-Cal for Families Premium Payment Section at (800) 880-5305 to arrange for the payment.

The NOA instructs the client to contact their county worker, whose name and number is on the NOA, when they have made their payments.

Note: Once the non-payment condition occurs, the client must pay all past-due payments in order to be considered current.



NPP Termination NOA Language Below is language to be used on the discontinuance NOA when the reason for discontinuance is non-payment of premiums.

Premiums have not been paid for the child named above, for at least two months.

If you have any questions about this action or if there are additional facts relating to your circumstances, which you have not reported to us, please write or call your worker. Your worker’s name and telephone number are above. If you wish to pay the premiums and remain eligible for Medi-Cal, please contact the Medi-Cal Premium Payment Section at (800) 880-5305 to arrange for repayment and then let your worker know you have paid your premiums.

Please remember that this action pertains only to the current circumstances and that you may reapply at any time. Please note that you may be required to pay past due premiums if your child(ren) become eligible for Medi-Cal with a premium in the next twelve (12) months.

6. EW If an EW is contacted by a client, who states he or she has repaid past due premiums, the EW can verify the payment status by calling the Maximus County Liaison at (916) 673-4602 and then proceed to stop the discontinuance.

If the client pays the past due premiums...

Then...

After discontinuance, but within the following 30 days,

The EW must verify the payment status and reinstate the premium aid code so the client has no break in coverage.

To ensure the client has had sufficient notification and time to respond to DHCS’ request for payment, the client has a period of at least 90 days to pay past due premiums, beginning with the first notification of past due premiums sent by MAXIMUS.

NOTE: The 90-Day Cure period does not apply to NPP. The 90 days referenced above only applies to the period of missed payments, not from the discontinuance date.

More than 30 days after the discontinuance,

The client must submit a new application.

If determined eligible for the OTLIC in a premium aid code and there are past due premiums from the previous 12 months still outstanding, the past due premiums will be included on their first premium statement and subsequent statements until paid in full or the client is discontinued.

Step Who Action



Welfare & Institution Code § 14005.26 authorized this decision. If you believe this is incorrect, you can contact your county office or file an appeal. See “Your Hearing Rights” on the last page to learn how to appeal. You have only 90 days to ask for a hearing. The 90 days started the day after the county sent you this notice.

CalWIN Process The following steps must be taken to discontinue for non-payment of premium in CalWIN:

Step Action

1. • On the Display Individual Eligibility Summary window, [Program] tab, select the individual and click on the [Health Care] button.

• On the Display Health Care Program window, verify that the individual is Passing with either a premium Aid Code and a Y is on the Final Aid Code column.

2. On the Collect Case Individual Detail window:

- Enter the current date as the Effective Begin Date field.

- Select Individual not paying premium from the Reason field.



Premium Waiver and Refund Requests

MAXIMUS will automatically refund premiums to clients under certain circumstances, such as balances paid several months in advance; however, there are instances in which the refund or waiver of premiums must be initiated by the EW.

3. Run EDBC and Authorize the Medi-Cal Fail for the individual.

4. • On the Display Individual Eligibility Summary window, [Program] tab, select the individual and click on the [Health Care] button.

• Review the Display Health Care Program window, verify that the individual has: Eligibility Status of Fail for the premium Aid Code and a N is on the Final Aid Code column.

5. On the Search for Printed Correspondence window, ensure that Correspondence MC 239A- TLICP Discontinuance is generated in CalWIN and sent to the client.

6. Two working days later, review MEDS to confirm the individual has been discontinued.

Step Action



The EW must initiate the premium refund or waiver request when:

• The client has provided proof of American Indian and Alaskan Native (AI/AN) ancestry. Proof is either a:

• Copy of the American Indian or Alaskan Native enrollment document from a federally recognized tribe,

• Certificate of Degree of Indian Blood from the Bureau of Indian Affairs, or

• Letter of Indian Heritage from a California health clinic.

• The client’s request to be discontinued is not effective by the last day of the month in which the request is made,

• The client’s eligibility status changes and is reported retroactively to MEDS as being eligible in a non-premium aid code (e.g. zero SOC MC), or

• It is the result of an Administrative Law Judge’s Decision through the appeal and hearings process.

The client’s request for discontinuance must be in writing, scanned into IDM and documented in the CalWIN Maintain Case Comments window. Eligibility in OTLIC is for the entire month and clients cannot be discontinued at any time other than at the end of the month. client requests for discontinuance must only be prospective. EWs must not process a client’s request for a discontinuance made retroactively.

If the discontinuance action is not effective by the last day of the month in which the request is made, EWs must submit the Premium Refund/Waiver Request form, even if the client claims not to have paid for that time. A client who submits a written request for discontinuance may not have paid premiums for the time period they expected to be discontinued. The EW must request a premium waiver to ensure that any unpaid premiums do not become due again if the client is placed into an OTLIC premium-based aid code in the future.

Note:MAXIMUS is contractually obligated to continue billing the client until the premium-based aid code is no longer active in MEDS.



Premium Refund/ Waiver Process The following is the process for the county to process a OTLIC premium refund/ waiver request:

36.6.6 Non-Payment of Premium Questions and Answers

Question 1: Does Soft Pause affect the processing of NPP? Answer 1: Soft Pause does not affect processing of cases/individuals for NPP.

Step Who Action

1. EW • Makes appropriate data changes in CalWIN.

• Ensures that MEDS reflects the request. (i.e. discontinuance or change in eligibility aid code, etc.)

• Thoroughly documents in the Maintain Case Comments window of CalWIN actions taken, effective dates and written request (if needed) obtained.

• Complete the OTLIC Premium Refund/Waiver Request form (MCED 3233), including:

• Date, County (Santa Clara), EW Phone Number (Not a general office phone number), and Fax Number

• Client Name, CIN• Reason for Refund or Waiver• Month(s)/Year to be Refunded or Waiver effective date• EW Name, EW Worker Number • EW Signature - The EW’s signature signifies that the EW verifies the

cases has been researched, and the refund/waiver request is valid. Forms without an EW signature will not be processed.

• Fax the MCED 3233 form to (866) 848-4977

2. MAXIMUS • Processes the requests following premium payment refund or waiver business rules.

• For the months that the county staff worker identifies, MAXIMUS will:

• Refund premiums if the beneficiary paid for those months, or

• Waive the premiums if the beneficiary had not paid.

3. EW staff Direct the beneficiary to call MAXIMUS- Premium Payment Section at 1-800-880-5305 to inquire about the status and timeframe for the requested refund/waiver.

Note: The client may continue to receive premium due invoices after a discontinuance from the premium-based aid code due to the billing cycle. Once a client is discontinued, there may be an overlap between the mailing of the future month’s invoice and the reconciliation of MAXIMUS’ system with MEDS.



Question 2: Does the client need to reapply after 30 days or does the 90-day cure period apply? Answer 2: For NPP, if full payment is not submitted within the 30 days after the NOA the client must reapply. The client has already received at least a 90 day notice period at the point of discontinuance; the client will ahve had a period of at least 90 days to pay the past due premiums. Beginning with the first notificiation of the past due premiums sent by MAXIMUS (the vendor that takes the payments). The “90-day cure period” does not apply to NPP cases.

Question 3: If the parents are on Soft Pause at the time of discontinuing the children should the EW leave the parents on Soft Pause or release the Soft Pause and terminate the parents, as well? Answer 3: Leave the parents on Soft Pause until the Non-MAGI MC determination is declined, completed or discontinued due to non-response per MC Update 2016-16 and MC Handbook Chapter 19 Transitions.

Question 4: Should the EW terminate MC for children who are now receiving free MC (non-premium aid codes)? Answer 4: No. If a child is re-evaluated and is now on a non-premium aid code, a balance due for past premiums. The client may be required to pay past due premiums if the child(ren) become eligible for MC with a premium withing 12 months of NPP.

Question 5: Do children who are discontinued due to NPP receive CEC? Answer 5: No.

36.6.7 Bridging for AIM-Linked Infant

AIM-linked infants with family incomes up to 266% FPL will enroll in OTLIC. If at their annual Medi-Cal redetermination, the EW determines an AIM-linked child is above 266% FPL, the EW will need to forward the child’s case information back to MAXIMUS for reenrollment to the HF AIM program.

After the Annual RD is processed, the MC 210 RD must be forwarded to the HF AIM program along with all necessary verifications when ALL the following conditions are met:

• A child is an AIM-linked infant• A child is under age two• A child becomes ineligible for Medi-Cal in the month following the RD• Family income exceeds 250% of the FPL



To determine if a child is an AIM-linked infant, the EW will need to check in MEDS for the aid code 0C prior to the transition aid code of 5C or 5D. If the child has 0C prior to the transition aid code, then this child is an AIM-linked infant.

The EW will use aid code 7X to bridge the AIM-linked child to HFP for the continuation of benefits under the HFP program.




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