35. Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)

Transcription

1 Medi-Cal Handbook page Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC) The following Medi-Cal Continued Eligibility programs are established: Effective January 1, 1991, the federal Omnibus Budget Reconciliation Act (OBRA) of 1990, provides Continued Eligibility (CE) for pregnant women and infants up to age one when their is a change in family income. Assembly Bill (AB) 99 established the CE program effective October 1, Effective January 1, 2001, Assembly Bill (AB) 2900 (Chapter 945, Statutes of 2000), mandates a new Medi-Cal provision for Continuous Eligibility for Children (CEC) under age 19. CEC ensures that all children under age 19 who are determined eligible for zero share-of-cost Medi-Cal will maintain eligibility until the next redetermination or until the child turns 19, whichever occurs first. Effective October, 2003, the Continued Eligibility (CE) provision for infants under age one was changed to Deemed Eligibility (DE) to emphasize the distinction between Continuous Eligibility for Children (CEC). Effective February 4, 2009, the Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) reauthorized funding for the State Children s Health Insurance Program (CHIP), expanded coverage to children and changed DE requirements for infants Overview - Continued Eligibility for Pregnant Women and Infants Effective January 1, 1991, the federal Omnibus Budget Reconciliation Act (OBRA) of 1990, provides continued eligibility for pregnant women and infants up to age one when there has been a change in family circumstances. Under this program: Once a pregnant woman has been approved for Medi-Cal, increases in the share of cost due to increased income are not counted in her share of cost determination for pregnancy-related services, throughout the pregnancy, until the end of her 60-day postpartum period. Changes in MFBU or Maintenance Need Levels may affect the share of cost. Update # Revised: 02/03/16

2 page 35-2 Medi-Cal Handbook An infant whose mother is eligible for and receiving Medi-Cal in the month of delivery is automatically deemed eligible for one year without a separate application or SSN. Increases in the family's share of cost due to increased income or other changes in the MFBU are not counted in the newborn's share of cost determination until the child reaches age one. Pregnant women and infants must continue to meet other eligibility criteria, such as residency requirements. Increases in family income must be applied to all other persons in the MFBU and to a pregnant woman's non-pregnancy related services. Decreases in family income will continue to be applied to everyone in the MFBU, including pregnant women and/or infants under age one. However, any subsequent increases in income will be disregarded for the pregnant woman and infant under age one Affected Persons All Medi-Cal eligible pregnant women and infants (up to one year old) are potentially eligible for Continued Eligibility (CE)/Deemed Eligibility (DE), including those who are: Medically Needy (MN) or Medically Indigent (MI) and, due to an increase in family income or other changes in the MFBU, would change from no share of cost (SOC) to a SOC; or, would have a higher share of cost. Eligible under the Income Disregard and Property Waiver Programs with no SOC, and, due to an increase in income, would become ineligible for those programs. Minors who are receiving pregnancy related services under the Minor Consent Program. Public Assistance (PA) or Other PA recipients and, due to an increase in income, lose PA/Other PA eligibility and their no SOC Medi-Cal benefits. PA refers to cash benefits, such as CalWORKs or SSI/SSP. Other PA refers to cash-based Medi-Cal benefits, such as TMC (Aid Codes 39 and 59) and Edwards (Aid Code 38). Revised: 02/03/16 Update # 16-03

3 Medi-Cal Handbook page Eligibility, General Continued Eligibility is intended to provide Medi-Cal, without increasing the share of cost, for the mother's pregnancy-related services and for the infant's medical care for the first year regardless of any increases in family income. EWs are to process a case that includes a pregnant woman or infant under age one as follows: Step Action 1. Apply regular Medi-Cal eligibility procedures for MN or MI. 2. Apply Sneede budgets, if applicable. 3. Review for eligibility under the Income Disregard/Property Waiver program, if there is a share of cost. 4. Review for Deemed Eligibility. 5. Apply Hunt v Kizer (old, unpaid medical expenses) to the SOC, if applicable. *Exception: An unmarried father is not required to be in the MN/MI MFBU until the month following the month that the child turns age one, unless he is requesting Medi-Cal for himself and/or any of his other mutual or separate children. (NOTE: This does NOT apply to Section 1931(b) Medi-Cal.) [Refer to Unmarried Fathers - MN/MI Medi-Cal, page 35-7 for more information.] CE only disregards increases in income, not decreases in the MFBU composition or maintenance need level that result in a SOC Eligibility for Pregnant Women Only a pregnant woman who is eligible for and receiving Medi-Cal in the month of birth is eligible for Continued Eligibility (CE). She must have met her share of cost (been certified) at least ONCE during her pregnancy, prior to, or in the same month as, the income increase, in order for her to qualify for Continued Eligibility (unless she is eligible under the Income Disregard Program). Continued Eligibility does NOT apply to any woman who receives Retroactive Medi-Cal coverage for the month of delivery. Update # Revised: 02/03/16

4 page 35-4 Medi-Cal Handbook Increases in the income or the property of the unmarried father do NOT affect the pregnant woman, regardless of whether he wants Medi-Cal for himself or other children. Increases in her husband's income do not affect her SOC, however changes in his property do affect her eligibility, unless she is eligible for the Property Waiver Program Adding Newborns, General Procedures to establish eligibility for the newborn are as follows: Step Action 1. Advise the mother to contact the EW once the child is born, as the baby's name, sex, date of birth, and residence must be known in order to establish eligibility. 2. If the birth has not been reported by the end of the expected birth month, contact the mother by the end of the following month. 3. Document at least two attempted contacts and follow SB 87 procedures before end-dating the pregnancy (or discontinuing the case if no one remains eligible). 4. Issue the baby's own BIC card effective the month of birth, even though the mother's card will cover services during the month of birth and the following month. 5. Have the mother obtain the baby's SSN and Birth Certificate as soon as possible, even though under CE rules it is not required until the child is one year old. If the mother provides the SSN prior to one year of age, the infant s real SSN must be reported to MEDS and used. This enables the child, at age one, to continue Medi-Cal eligibility without delay. A DE infant cannot be discontinued for not having an SSN of file until age one. REMINDER: Regular SSN requirements apply if the mother is not Medi-Cal eligible in the month of birth Newborn Referral Form (MC 330) Background Historically, EWs have relied on parents or family members to report the birth of a child. To compensate for any initial delay in establishing the infant s eligibility, Medi-Cal regulations allow services for a newborn to be billed on the mother s Medi-Cal card for the month of birth and the following month. Timely issuance of a Medi-Cal card for the infant still requires timely reporting of the birth. Revised: 02/03/16 Update # 16-03

5 Medi-Cal Handbook page 35-5 The Newborn Referral Form (MC 330) was developed by the state Department of Health Care Services (DHCS) to facilitate the enrollment of DE newborns into Medi-Cal. Newborn Referral Procedure-Provider A supply of newborn referral forms is available to Medi-Cal providers who serve Medi-Cal eligible pregnant women, including hospitals, clinics, urgent care centers, independent nurse-midwives, and others. When a child is born to a Medi-Cal mother, the provider will: Obtain the written consent of the infant s parent or guardian, Complete the MC 330 with the mother s address, SSN and information on the newborn and forward the referral by mail or fax to the Benefits Service Center (BSC) for processing. The form may also be submitted or faxed to any district office by the client. Newborn Referral Procedure Each MC 330 received must cleared in CalWIN/MEDS and processed as follows: If the Mother... Is active in another county, Is active on Medi-Cal in Santa Clara County, Then the Referral Will Be... Forwarded to the county of record by designated staff. Forwarded to the appropriate District Office for assignment. Use the information from the referral form to activate the infant on the mother s Medi-Cal case. Contact the parent if the infant was never reported as an unborn. Is receiving SSI/SSP, BCCTP, or MCEIP Medi-Cal benefits at the time of birth, Processed as an application if no other family members are receiving Medi-Cal. Establish a case for the infant under the 200% Income Disregard/Property Waiver program using the infant s name, date of birth and gender and information available on MEDS for the mother. Update # Revised: 02/03/16

6 page 35-6 Medi-Cal Handbook If the Mother... Has no active case record, Then the Referral Will Be... Held for 30 days, then file-cleared again in CalWIN/MEDS. If the case is found to be active or pending at that time, the referral will be forwarded to the appropriate office for task assignment. If no case is found to be active at that time, a Medi-Cal Notice of Newborn Referral (SC 1374) must be completed and sent to the parent by the designated staff. If the child has an active Accelerated Enrollment (AE) or CHDP Gateway MEDS record, the referral will be forwarded to AAC for processing. REMINDER: Staff must enter the date of application recorded on the MEDS INQP screen. The MC 330 must be scanned into IDM under F1-Applications. Medi-Cal Notice of Newborn Referral Form (SCD 1374) The Medi-Cal Notice of Newborn Referral (SCD 1374) must be completed and sent to the parent/caretaker relative by designated clerical staff when no active record is found after 30 days. As part of our county s Medi-Cal outreach effort, the notice explains to the new mother that she may apply for Medi-Cal if she wishes. The SCD 1374 informs the parent that the county has no Medi-Cal case record and he/she must contact the Social Services Agency to apply for Medi-Cal. The MC 330 Newborn Referral form is NOT an Application for Medi-Cal. Therefore no Mail-In application packet is to be sent with the SCD Reminder: Infants born to mothers receiving SSI/SSP, BCCTP or MCIEP at the time of birth are also deemed eligible. The Medi-Cal case must be established by using the information available on the MC 330 and the mother s MEDS record. Revised: 02/03/16 Update # 16-03

7 Medi-Cal Handbook page Unmarried Fathers - MN/MI Medi-Cal This section does NOT apply to Section 1931(b) Medi-Cal. [Refer to Pregnant Woman, page for information about unmarried fathers of unborns in the Section 1931(b) program.] MFBU An unmarried father living in the home is not required to be in the MN/MI MFBU until the month following the month that his child turns age one, unless he is requesting Medi-Cal for himself and/or any of his separate or mutual children. The unmarried father must be added to the MFBU the first of the month after the infant turns one year old. Income/Property Increases in the income or property of an unmarried father DO NOT affect the infant until the child reaches age one, regardless of whether the unmarried father wants Medi-Cal for himself or other children. [Refer to Sneede, page 35-8.] EWs are not required to verify the income or resources of an unmarried father (who does not want Medi-Cal for himself or other children) until the infant turns age one. U-Parent Linkage If an unmarried pregnant woman or the unmarried father in the home is unemployed, it is important that EWs explore and explain the benefits of establishing AFDC-MN eligibility based on unemployment. If there is linkage: The mother's eligibility can be continued after the 60-day postpartum period. The unmarried father may be eligible. EWs shall determine AFDC-MN (Aid Codes 34 or 37) linkage for the unmarried pregnant woman whenever possible. If... AFDC-MN linkage for the pregnant woman is dependent on the cooperation of the unmarried father in the home. Then the EW shall... Document in [Maintain Case Comments] whether or not he wishes to cooperate in establishing linkage for the pregnant woman. Update # Revised: 02/03/16

8 page 35-8 Medi-Cal Handbook If... The unmarried father is willing to provide employment information, have him complete an MC 210 S-W The unmarried father does not cooperate in providing information, and AFDC-MN linkage for the pregnant woman cannot be established otherwise. Then the EW shall... Establish eligibility for the pregnant woman under AFDC-MN (Aid Codes 34 or 37) if U-Parent deprivation exists. Establish eligibility for the pregnant woman under the MI program (Aid Codes 86 or 87). Information Provided Although an unmarried father is not required to be in the MN/MI MFBU until the newborn reaches age one, occasionally he may provide all necessary information and verifications. When this occurs: He may be included in the MFBU. If adding him adversely affects the mother or child (results in excess property or a share of cost) then Sneede rules apply. It is easier for EWs to allow him to opt out of the MFBU at application if he chooses to do so. However, it is not an error to include him if Sneede procedures are followed, because the end results will be the same. (NOTE: The unmarried father of an unborn must always be included in the MFBU for Section 1931(b) Sneede In cases where there is an unmarried father in the home and the MFBU has a share of cost or excess property, the following rules apply when determining eligibility for the newborn: After the baby is born, the child's eligibility is tied to the mother. If the unmarried father wants Medi-Cal for himself or for his other mutual children and there is a SOC or excess property, Sneede rules apply. [Refer to Court Orders: Sneede v Kizer, page 70-1.] Include the newborn under age one in the Responsible Relative determination, even though the newborn will not actually receive an allocation from the unmarried father until the month after the child turns age one. There is to be NO ALLOCATION FROM THE UNMARRIED FATHER TO THE INFANT during Continued Eligibility. Revised: 02/03/16 Update # 16-03

9 Medi-Cal Handbook page 35-9 Mother's income, before any increases, is allocated to the baby. If a pregnant woman/infant are included in an MBU that has a SOC, evaluate them under the poverty level programs. If a SOC remains and they had no SOC or a lower SOC in the prior month, apply Continued Eligibility rules Medical Support Enforcement For purposes of medical support enforcement, an absent parent still has a legal responsibility for the health and welfare of his child(ren). A medical support referral must be made at the end of the mother s 60-day postpartum period if there is an absent parent Three Month Retroactive Use actual income to determine the share of cost for each retroactive month requested. Once an increase in income is reported subsequent to the month of application, the increase is to be disregarded. Increases in income after the month of application trigger Continued Eligibility, not the family's income in the retroactive months or the date of the initial interview. Example 1: A woman applies for Medi-Cal on 10/30/11. She had a baby 10/5/11. She requests Retro Medi-Cal for August and September. She completes the application process on 11/15/11. Her net nonexempt income is as follows: (Retro) (Retro) (App. Mo.) (Current Mo.) 8/11 9/11 10/11 11/11 None $1,000 $1,200 $1,800 Actual income is budgeted for August and September. In November, her income is much higher. Since she applied during the month of October, the income increase in November is disregarded under Continued Eligibility rules. Even though she applied after the baby was born, October is not a Retro month; therefore, CE rules apply. Once her SOC for 10/11 is certified, she receives zero SOC postpartum services for November and December. The newborn's SOC is based on October's income until the child turns age one, unless income decreases. Update # Revised: 02/03/16

10 page Medi-Cal Handbook An infant can receive DE retroactively when one of the three months prior to the application month is the infant s birth month and the mother, parent, legal guardian or responsible relative of the infant requests Medi-Cal coverage for that month. If the infant s mother had Medi-Cal eligibility in the birth month, then apply DE to the infant beginning in that retroactive month. Example 1: A mother applies for Medi-Cal on July 6, 2011 for herself and her infant. The infant s date of birth was June 16, The mother indicates on her application that she has unpaid medical bills for May and June and requests Medi-Cal for May and June. The EW approves Medi-Cal for July 2011 and ongoing. In determining her retroactive Medi-Cal eligibility, the EW determined that she was not eligible in May but eligible for June. Because the infant s month of birth is in the retro month of June and the mother was Medi-Cal eligible in June, the infant has DE beginning in June Break In Aid Once a pregnant woman and/or infant are no longer eligible for Medi-Cal, Continued Eligibility ends. Any break in aid causes Continued Eligibility to end. For example, a family moves from County A and fails to notify their EW, so the case is discontinued 10/31. The family reapplies in County B after the 30 day timeframe allowed by SB 87. This is considered a break in aid for purposes of determining Continuing Eligibility. County B determines eligibility and SOC based on November's income Intercounty Transfers (ICTs) If an ICT is received, the client is entitled to CE, per the requirements set forth in this section, as no break in aid occurs. When initiating an ICT for a beneficiary who is entitled to CE, EWs must include adequate documentation/explanation for the Receiving county Whereabouts Unknown If the mother s and infant s whereabouts become unknown, the case may be discontinued with a timely notice of action after following SB 87 procedures for loss of contact. However, if the family reestablishes contact, and the infant remained in California continuously since the discontinuance, the following applies: Revised: 02/03/16 Update # 16-03

11 Medi-Cal Handbook page The infant s eligibility must be restored back to the date of discontinuance and through the current month. Even if the infant reached age one or ceased to reside with the mother at some point during the period of discontinuance, the infant s eligibility is uninterrupted because no timely NOA was given. If CE requirements were met in every month of the discontinuance period, the EW must determine whether the requirements are expected to be met in the future month. If so, CE continues. If the EW determines that the infant did not meet the requirements in any of these prior months, the EW must determine whether the infant has Medi-Cal eligibility on any other basis. If no other basis for eligibility exists, the infant can be discontinued with a timely notice of action Annual Redeterminations The following requirements apply when an MFBU includes a pregnant woman and/or a child under age one: Redeterminations must be completed annually as a condition of eligibility for pregnant women. The infant is given the same annual redetermination as the rest of the family and will have his/her annual RD completed along with the family s, even if the family s annual redetermination date is before the infant s first birthday. Deemed eligibility continues until age one regardless of any adverse actions that may apply to the rest of the family. Failure of the mother to complete the annual RD only affects the mother s eligibility and does not affect the infant s deemed eligibility. Regular Medi-Cal requirements apply for the mother and other family members if the client fails to complete the annual RD or provide all necessary information or verifications to complete the RD. Important: For AFDC/MN-MI Medi-Cal, do not request verification of the income or resources of the unmarried father in the home prior to his child's first birthday, unless he and/or his other mutual or separate children are receiving Medi-Cal. If it is determined at RD (or any other time) that the mother has excess property, the mother would be ineligible, and the baby would no longer be deemed eligible (unless eligible under the Property Waiver Program). Update # Revised: 02/03/16

12 page Medi-Cal Handbook Increased Income, Pregnant Woman (MN/MI Programs) Use this chart to determine under which program a pregnant woman's eligibility continues when there is an increase in family income or SOC: If the Prior Month Aid is... No SOC, MN/MI or PA/Other PA Income Disregard Program (between Maintenance Need and 200% of FPL) Property Waiver Provision SOC, MN/MI (Income over 200%) And Income Increases... But does not exceed Maintenance Need Between Maintenance Need and 200% of FPL Over 200% At or Below 200% Over 200% At or Below 200% Over 200% Still Over 200% Then Continue Eligibility for the Pregnant Woman under... MN/MI, no SOC. (Unaffected by Continued Eligibility) Income Disregard Program for pregnancy related services. Increase her SOC for nonpregnancy care. Income Disregard Program for pregnancy related services. Increase her SOC for nonpregnancy care. Income Disregard Program for pregnancy related services. Increase her SOC for nonpregnancy care. Income Disregard Program for pregnancy related services. Increase her SOC for nonpregnancy care. Property Waiver Provision for pregnancy related services. Property Waiver Provision for pregnancy related services. (Use Income Disregard Program Aid Code.) Continue pregnant woman at prior month's SOC for both her pregnancy and nonpregnancy services. Decreases in family income are still considered. Revised: 02/03/16 Update # 16-03

13 Medi-Cal Handbook page Increased Income, Infants (MN/MI Programs) Use this chart to determine under which program an infant's eligibility continues through the month that the child turns age one, when there is an increase in family income or SOC: If the Prior Month Aid is... No SOC, MN/MI or PA/Other PA Income Disregard Program (between Maintenance Need and 200% FPL) Property Waiver Provision SOC, MN/MI (Income over 200%) And Income Increases... But does not exceed Maintenance Need Between Maintenance Need and 200% of FPL Over 200% At or Below 200% Over 200% At or Below 200% Over 200% Still Over 200% Then Continue Eligibility for the Infant under... MN/MI, no SOC. (Unaffected by Continued Eligibility) Income Disregard Program. No SOC. Income Disregard Program. No SOC. Income Disregard Program. No SOC. Income Disregard Program. No SOC. Property Waiver Provision. No SOC. Property Waiver Provision. No SOC. (Use Income Disregard Program Aid Code.) Continue infant at prior month's SOC. The SOC for other MFBU members is increased, except for a pregnant woman's pregnancy related services. Decreases in family income are still considered Increased Income, PA/Other PA Recipients/Section 1931(b) Pregnant women and infants who are discontinued from CalWORKs, Section 1931(b), Transitional Medi-Cal (TMC), or Edwards are potentially eligible for Continued Eligibility. Update # Revised: 02/03/16

14 page Medi-Cal Handbook Determine eligibility for no share of cost (SOC) Medi-Cal in the following sequence: Step Action 1. When a pregnant woman and/or infant under age one is discontinued from CalWORKs, first determine eligibility under the Section 1931(b) program. NOTE: Edwards Medi-Cal is appropriate if there is NOT enough information in the case record to determine ongoing Medi-Cal eligibility. Once there is a break-in-aid, Continued Eligibility ends. 2. If ineligible for Section 1931(b), determine eligibility for no SOC under Transitional Medi-Cal (TMC). 3. If ineligible for TMC, determine ongoing Medi-Cal eligibility under the MN/MI programs. Disregard increases in family income for the pregnancy related services and for the infant's SOC determination. If Income is: At or below Maintenance Need Level Above Maintenance Need Level (regardless of how high the income is) Then Establish Medi-Cal under: MN/MI Program, No SOC, unaffected by Continued Eligibility. Income Disregard Program for: Pregnancy related services, and A child under age one. Apply full SOC to: Other family members, and The pregnant woman's nonpregnancy care. NOTE: Other children in the MFBU may be eligible for No SOC under Federal Poverty Level programs Determining MFBUs/SOC The following examples describe situations when family income increases: Example 1 A family of 4 includes Mom (pregnant), Dad, and their 4 year old child. At application the family income is between Maintenance Need and 200% of FPL. Dad is ineligible, as he is fully employed. (All family members are citizens.) Revised: 02/03/16 Update # 16-03

15 Medi-Cal Handbook page Three months later, the family reports income over 200% of FPL. The increased SOC is applied to all MI family members the first of the following month. Mom stays active under the Income Disregard Program with the same Aid Code until the end of the 60 day postpartum period, without regard to any increases in income. The newborn will later be activated under the Income Disregard Program. Increases in family income will not affect the newborn until age one, as long as other eligibility criteria are met. Example 2 A family of 3 (Mom, Dad and their unborn) is currently eligible for Section 1931(b) Medi-Cal. Dad is an unemployed PWE. In January the infant is born and is added to the Section 1931(b) MFBU. In March, Mom returns to work and the family becomes ineligible for Section 1931(b) due to her earnings. Section 1931(b) is discontinued and the first 6 months of TMC is approved (April thru September). The family does not qualify for the second 6 months of TMC because their income is too high. The EW approves AFDC-MN with a SOC. Since the child is not yet one year old, DE applies. He/She is not affected by any increase in family income. Therefore, the child is issued zero SOC Medi-Cal under the 200% FPL program. Example 3 An unmarried pregnant woman lives alone and has net nonexempt income of $1000 per month; therefore, she is eligible for the 200% Income Disregard Program with no SOC for her pregnancy related services. During her pregnancy, her income increases to $1500. Continued Eligibility Rules: Her SOC is increased only for non-pregnancy care, Aid Code 37. She continues on the Income Disregard Program for her pregnancy care until the end of the 60 day postpartum period, Aid Code 44 (citizen). At the end of the 60 day postpartum period, she is discontinued from the Income Disregard Program and her full scope Medi-Cal continues with a SOC. The newborn continues to be eligible under the Income Disregard Program, with no SOC, through the month the child attains age one, provided all other DE eligibility factors are met. Update # Revised: 02/03/16

16 page Medi-Cal Handbook Example 4 A family of 4 includes Mom (pregnant), Dad, and their 3 year old child. In October Dad is fully employed and net nonexempt income is over 200% of FPL, so they have a share of cost of $1150. In December they report increased earned income, and the new SOC is $1450. Mom's SOC is frozen at the lower SOC. The pregnant woman continues under the lower SOC amount for both her pregnancy and non pregnancy related services. MEDS does not allow an individual to have two different SOC amounts with the same Aid Code simultaneously in the same month. Change in MFBU Size Continued Eligibility rules apply when changes in the size of the MFBU and/or in the Maintenance Need Level cause an increase in the SOC. For example, a family member moves out of the house, but the household's income remains the same. The SOC increases due to the new, lower Maintenance Need Level. The SOC increase is NOT applied to the pregnant woman and/or infant Deemed Eligibility for Infants Overview Infants born to women who are eligible for and receiving Medi-Cal on the date of the infant s birth are automatically deemed eligible for Medi-Cal for one year: Without a separate Medi-Cal application, and Without requiring a Social Security Number (SSN) for the infant, and Without considering the infant s living arrangements or the mother s eligibility status. A new application (SAWS 1) is required when the child turns age one only in those cases when the mother is ineligible and no one else in the family is receiving Medi-Cal. A new MC 210 or MC 321 HFP is not required if there is one on file which was completed within the last 12 months. Revised: 02/03/16 Update # 16-03

17 Medi-Cal Handbook page Program Eligibility Under DE, the infant s eligibility in the birth month is based on the mother s no SOC or SOC eligibility on the date of the infant s birth, except that an infant covered under the mother s Medi-Cal BIC receives full-scope benefits even if the mother only has restricted benefits. If the mother was in the Medically Needy/Medically Indigent (MN/MI) program with a SOC that she met in the month of the infant s birth, the infant is in the MN/MI program with a SOC. If the mother is in the Income Disregard program, the infant is also in the Income Disregard program. If the mother is receiving Medi-Cal under the Supplemental Security Income/State Supplementary Payment (SSI/SSP) program, the Federal Breast and Cervical Cancer Treatment Program (BCCTP), or the Medi-Cal Inmate Eligibility Program (MCIEP) and the mother has Medi-Cal eligibility in the month of the infant s birth, the infant has DE for Medi-Cal without a separate application and is eligible for no SOC Medi-Cal. Notification may come from the parent, legal guardian, responsible relative or authorized representative, or the Newborn Referral Form (MC 330) from the hospital. Since the infant cannot be placed into the mother s Aid Code, he/she must have eligibility established under the Income Disregard/Property Waiver program. A new Medi-Cal case will need to be established if there is no previous case history. The annual RD is due when the infant turns age one. If there are other family members on Medi-Cal, or the infant s father is now requesting Medi-Cal, the infant is included in the same MFBU for regular Medi-Cal eligibility. [Refer to 22- for procedures to establish Medi-Cal eligibility for this deemed infant.] Residency California residency is a federal requirement to receive Medi-Cal. As long as the infant resides in California, the infant meets the residency requirement for DE. DE does not continue when an infant moves from the state of birth where he/she initially received DE to another state. When a DE infant moves to another state, the DE terminates. Likewise, when an infant with DE arrives from another state, he/she is not DE eligible because the infant s mother was not eligible for and receiving Medi-Cal in California on the date of birth. Update # Revised: 02/03/16

18 page Medi-Cal Handbook Deficit Reduction Act (DRA) of 2005 DE infants are exempt from DRA citizenship and identity requirements in perpetuity. Children born in the U.S. to a woman who is eligible for and receiving Medi-Cal on the infant s date of birth are deemed to have provided satisfactory documentation of citizenship and identity and are not required to provide any additional documents. Infants Born to Minor Consent Mothers Infants born to mothers receiving limited scope pregnancy related services under the Minor Consent Program Aid Code 7N do not qualify for DE due to the fact that Minor Consent is a state-only program, therefore an application is required. DE is a federal provision that requires an infant be born to a woman eligible for and receiving medical assistance under the State Plan. Reminder: Establish the case for the newborn using a separate case number from the Minor Consent case. Infant Born to Youths Receiving Adoption Assistance Program (AAP) Benefits Under the AAP program Medi-Cal is automatically included as a part of the benefits. Infants born to mothers who are receiving AAP are eligible for Medi-Cal under the DE for Infants program. When the FC bureau is notified that a youth receiving AAP benefits has had a baby the FC bureau must open a new case only for the infant and the infant s mother. FC Clerical is only required to complete the Application Registration then forward the case number and the application for Medi-Cal Expedited Enrollment to District Office. The infant cannot be added to an existing AAP case. Once the case is approved in District Office it follows current MC policy. The following process must be followed when an infant is born to a mother receiving AAP benefits: Step Who ACTION 1. FC Clerical/FC EW Receives notification the AAP youth has had a baby. Revised: 02/03/16 Update # 16-03

19 Medi-Cal Handbook page Step Who ACTION 2. FC EW Reviews the application/request forwards to FC Clerical for Application Registration for Medi-Cal only. 3. FC Clerical Completes the Application Registration for Medi-Cal with only the Infant and the Infant s mother and forwards the following information to District Office. This process only applies to DE infants that initiated at the FC Bureau Retroactive Eligibility SCD 1374 FC, When available, the Application, A copy of the CalWIN Inquire On Case Information Window, and Any additional information provided by the adoption SW, adoptive parents, and/or the youth receiving AAP benefits. 4. District Office Receives the Application and approves Medi-Cal. The infant s redetermination of benefits has no effect on the open AAP case. An infant can receive DE retroactively when one of the three months prior to the application month is the infant s birth month and the mother, parent, legal guardian or responsible relative of the infant requests Medi-Cal coverage for that month. If the infant s mother had Medi-Cal eligibility in the birth month, then apply DE to the infant beginning in that retroactive month. Example 1: A mother applies for Medi-Cal on July 6, 2011 for herself and her infant. The infant s date of birth was June 16, The mother indicates on her application that she has unpaid medical bills for May and June and requests Medi-Cal for May and June. The EW approves Medi-Cal for July 2011 and ongoing. In determining her retroactive Medi-Cal eligibility, the EW determined that she was not eligible in May but eligible for June. Because the infant s month of birth is in the retro month of June and the mother was Medi-Cal eligible in June, the infant has DE beginning in June. Example 2: A mother moves to California in July and applies for Medi-Cal on July 6, 2011, for herself and her infant. The infant s date of birth was June 16, The mother requests Medi-Cal for the retro months of May and June on her application. The Update # Revised: 02/03/16

20 page Medi-Cal Handbook EW approves Medi-Cal for July 2011 and ongoing. In reviewing the mother s retroactive Medi-Cal eligibility, the EW determines that the mother was not eligible in May or June because she did not meet the California residency requirement. Since the infant s birth month is in the retro month of June and the mother was not Medi-Cal eligible in June, the infant does not have DE. Example 3: A mother applies for Medi-Cal on July 1, 2011, for herself and her infant. The infant s date of birth was May 28, The county approves Medi-Cal for July with a share-of-cost (SOC) for the mother and infant. In August, the mother requests Medi-Cal for April, May, and June. The EW determines the mother is eligible for Medi-Cal with no SOC in each of the three retro months. The retro determination changes the infant to Deemed Eligible with no SOC beginning May Example 4: A mother applies for Medi-Cal on October 1, 2011, for herself and her infant. The infant s date of birth was June 16, The EW approves Medi-Cal effective October 1, 2011, and ongoing. Several months later, the mother receives medical bills for July The mother requests retroactive Medi-Cal for July through September 2011 to cover the unpaid medical bills. The county determines the mother is not eligible for July but eligible for August and September. Because the infant s month of birth is June, which is not in one of the three retro months, the infant is not DE as the mother did not receive Medi-Cal in June Infant s SOC/No SOC The infant s share of cost (SOC) will remain, through the month that the child reaches age one, the same as the mother's SOC during the month of delivery, or lower if the family's income decreases during the child's first year. If the mother has no SOC Medi-Cal on the date of the infant s birth, the infant has DE with no SOC, regardless if the mother has full scope or restricted benefits. Important: A mother who is concurrently eligible for the Income Disregard program and Medi-Cal with a share-of-cost does not have to meet the share-of-cost for her infant to be deemed eligible. Enrollment by the mother in the Income Disregard program entitles the infant to deemed eligibility (DE) if the infant is otherwise eligible. However, an infant whose mother has not met or obligated her share of cost in the month of birth or whose mother received retroactive Medi-Cal in that month, is not automatically eligible. Revised: 02/03/16 Update # 16-03

21 Medi-Cal Handbook page Example 1: Mother eligible for no SOC Restricted Benefits Mother is eligible only for no SOC pregnancy-related Medi-Cal with restricted benefits in the month of July 2011 and gives birth to an infant on July 17, Because the mother was Medi-Cal eligible on July 17th, the infant has DE with no SOC until the end of the month in which the infant reaches age one. Example 2: Mother Eligible for no SOC Medi-Cal A mother receiving no SOC Medi-Cal in the month of May 2011 gives birth to an infant on May 31, In July, the mother becomes ineligible for Medi-Cal and her Medi-Cal is discontinued. Because the mother had no SOC Medi-Cal on the day of the infant s birth, the infant continues with no SOC Medi-Cal under DE until the end of the month in which the infant reaches age one. If the mother has eligibility for Medi-Cal with a SOC in the birth month and meets her SOC in the birth month, the infant has DE with the same SOC as the mother. In accordance with federal guidelines, an individual with a SOC is ineligible for Medi-Cal until the individual pays or obligates to pay his/her SOC. Therefore, unless the mother paid or obligated to pay her SOC in the birth month, the mother is not Medi-Cal eligible in that month and the infant would not have DE for Medi-Cal. The EW will need to verify the SOC obligation in MEDS prior to approving DE for an infant. Example 3: Mother s SOC Unmet in the Birth Month A pregnant woman has employer covered medical insurance. Her medical insurance has a high co-payment and does not cover some medical expenses for labor and delivery so she applies for Medi-Cal. The EW determines she is only eligible for Medi-Cal with a $700 SOC. She delivers her infant and pays her employer insurance copayment of $550. She does not meet or obligate to meet the remaining $150 of her $700 SOC in the birth month. Because she still has $150 of her unmet SOC, the mother does not receive Medi-Cal on the date of the infant s birth. Therefore, the infant is not entitled to DE. IMPORTANT: A mother currently eligible for restricted benefits under the Income Disregard Program and full-scope Medi-Cal with a SOC does not have to meet the SOC for her infant to have DE. Enrollment in the Income Disregard Program entitles the infant to DE as long as the infant is otherwise eligible for deeming. Example 4: Mother s SOC Met in the Birth Month: In February 2011, a pregnant woman applies for Medi-Cal and is eligible with a $350 SOC beginning February The woman delivers in July and meets her $350 SOC for the birth month of July. Because the mother met or obligated to meet Update # Revised: 02/03/16

22 page Medi-Cal Handbook her $350 SOC in the birth month, she is certified as meeting her SOC and therefore Medi-Cal eligible. The infant has the same SOC as the mother and has DE until the end of the month in which the infant reaches age one. NOTE: There will be instances during an infant s DE period that the mother s SOC is reduced. When the mother has a lower SOC, the infant will also have a lower SOC. Example 5: Mother s SOC Reduced A pregnant woman has eligibility for SOC Medi-Cal beginning February 2011 and ending January The woman delivers her baby in July and meets her SOC in that month. Her infant has DE with the same SOC amount as the mother until the end of the month in which the infant reaches age one. In August the mother s company furloughs its employees and the mother has a cut in pay. The mother s income goes down and she now has a lower SOC. The infant s SOC will also be lowered. If the mother s income continues to go down prior to the infant reaching age one, the infant s SOC will also continue to go down. If the mother s SOC decreases to zero, the infant will have zero SOC until the end of the month in which the infant reaches age one, even if the mother s income increases again and she goes from no SOC to SOC prior to the infant reaching age one because CE protects the DE infant. Example 6: Mother Met Her SOC in the Birth Month, Change in MFBU A pregnant woman and her 18-year old child have Medi-Cal eligibility with a SOC beginning February 2011 and ending January The pregnant woman delivers in July and meets her SOC in that month. The infant has DE with a SOC until the end of the month in which the infant reaches age one. However, the 18-year old member of the MFBU moves out of the household the following month. The MFBU and the maintenance need level decrease but the income of the MFBU does not change. This change results in a higher SOC. The infant s SOC also increased because the CE program only disregards increases in income, not the change in MFBU composition or Maintenance Need Level. Revised: 02/03/16 Update # 16-03

23 Medi-Cal Handbook page Expedited Enrollment Medi-Cal eligibility for infants may be established through receipt of: A Newborn Referral Form (MC 330) Telephone Call Letter, Facsimile, or Other Contact. The information provided must include sufficient information to link the infant to the mother s MEDS record or an open Medi-Cal case. The minimum basic information required for the mother is the Benefits Identification Card (BIC) or SSN. The required information for the infant is the name, gender and date of birth. EWs are not to request the following items to add the DE infant: Birth Certificate Social Security Number Income documentation Immigration Status Form (MC 13), or Medical Support Questionnaire (CW 2.1/CW 2.1Q). NOTE: A medical support referral must be made on the infant once the mother s 60 day postpartum period has ended if there is an absent parent. If the information in CalWIN/MEDS indicates the mother s case is closed, the infant s Medi-Cal must be approved effective the month of birth through the current month as long as the mother was Medi-Cal eligible at the time of birth. A DE infant who is no longer a California resident may be discontinued. A ten day notice of action (NOA) is not required. Update # Revised: 02/03/16

24 page Medi-Cal Handbook Activating DE for the Infant Follow the procedures below to activate DE: IF THERE IS... An open case with the mother only (pregnant woman only case), An open county case with the mother and other family members (1931(b), MN, etc.), THEN... Check MEDS to verify the mother s Medi-Cal eligibility on the infant s date of birth and whether or not she met her SOC. If eligible on the date of birth, add the infant to the mother s case. Check MEDS to verify the mother s eligibility on the infant s date of birth, and whether or not she met her SOC. If eligible, add the infant to the case. NOTE: When adding the infant, the change in circumstances may require additional information. If additional information is needed to redetermine eligibility for the MFBU, utilize the SB 87 process. A CalWORKs case, No open case but the mother receives Medi-Cal through another program, such as SSI/SSP, BCCTP or MCIEP, Authorize Medi-Cal immediately upon notification of the infant s date of birth, name and gender. Authorize cash aid per CalWORKs policy and procedures. Check MEDS to verify the mother s eligibility on the infant s date of birth. Establish a case with the mother as an ineligible person. If additional information is needed, contact the individual requesting Medi-Cal for the infant. Used the infant s date of birth to as the date of application Reporting Requirements All children under 21 are exempt from Midyear Status Report (MSR) reporting requirements. A DE infant does not need to submit an MSR. However, the infant s parent/caretaker relative must report any change in circumstances within ten days Change in County of Residence A change in county of residence within California does not affect the infant s DE. When an inter-county transfer (ICT) is received, the EW must review the information in the case file from the Sending County and continue the infant s DE. If there are changes to the family s circumstances that may affect the DE infant, the Receiving County will review and make the necessary changes. Revised: 02/03/16 Update # 16-03

25 Medi-Cal Handbook page DE Infant Approaches Age One Year Most changes in family circumstances do not affect the infant s eligibility, except death or moving out of state. A redetermination must be completed in the month the DE infant turns one year old using the SB 87 process to determine ongoing eligibility. The redetermination process will depend on the following situations: IF... The DE infant is in an open case with other family members, The DE infant is the only eligible individual in the Medi-Cal case and the mother receives Medi-Cal through SSI/SSP, BCCTP or MCIEP, All three steps of the SB 87 process are unsuccessful and the redetermination cannot be completed, Income information is available, but the EW is unable to obtain property information, The DE infant is the only eligible individual in a case where all other family members are discontinued, THEN... The current eligibility of the MFBU and annual redetermination (RD) date of the case applies to the infant. If the family has a SOC, review for a federal poverty level (FPL) program Determine ongoing eligibility for the infant. Follow SB 87 procedures to obtain necessary information to continue the child s Medi-Cal. Discontinue the infant for failure to cooperate. Determine eligibility for the FPL Property Waiver program. Follow the SB 87 process to obtain any necessary information to continue the infant s Medi-Cal. Example: The only person remaining as eligible in a Medi-Cal case is the DE infant (parents failed to complete the annual RD). The child turns one year old on January 4, In December 2011, the county initiates the SB 87 process to establish ongoing eligibility. If all three steps of the SB 87 process are unsuccessful, and current income information cannot be obtained, discontinue the infant for failure to cooperate. However, if the EW has enough income information but is unable to obtain property information, redetermine the child s eligibility under the FPL Property Waiver program Discontinued Family Reapplies During SB 87 Process If during the SB 87 process for the DE infant, or at any time prior to the end of the infant s DE period, any discontinued family members wish to reapply for Medi-Cal, a new application must be completed to obtain pertinent information to determine the family s eligibility. However, do not delay the infant s eligibility determination if Update # Revised: 02/03/16

26 page Medi-Cal Handbook information is available for the infant to continue Medi-Cal under another program. Instead, grant the infant s eligibility without regard to the pending application of the other family member(s). When the family s new eligibility is determined, add the infant in the family s case as an eligible MFBU member with the same RD date of the family Rescind DE Due to Loss of Contact When a family with a DE infant is discontinued for loss of contact and later the family reestablishes contact, reinstate DE for the infant, for any months discontinued due to loss of contact, unless the family lost California residency. Example 1: In December 2011, a Medi-Cal eligible family with a DE infant vacated their residence and there was no contact with the county. In January 2012, the parents MSR was due and the county received mail returned from the United States Postal Service, which showed there was no forwarding address. After completing the SB 87 process the EW was not able to contact the family and discontinued the case for loss of contact. On April 27, 2012, the family moved to Arizona for a job opportunity. The family established residency in Arizona in May but returned to reside in California in August 2012 because the business closed. The family contacts the county to reinstate their Medi-Cal benefits in August. The family resided in California until April 27, Because the family retained California residency from December through April, the infant retains DE for those months. DE must be reinstated for the infant for the months of December through April. When the family moved out of California, the deemed infant lost DE. Example 2: A Medi-Cal case with a mother and her two-month old DE infant. The mother moves and leaves her infant with a relative. Because the relative had no knowledge that the mother received Medi-Cal, they did not contact the county. The EW sends information to the mother that requires a response. The mail is returned without a forwarding address and after completing the SB 87 process, the EW discontinues the case for loss of contact. After four months, the relative contacts the county to request Medi-Cal for the infant. The EW finds that the infant received Medi-Cal as a DE infant under the mother s closed Medi-Cal case. DE must be reinstated for the infant under the mother s old case for the months where there was loss of contact. Eligibility continues for the infant in that case until the end of the month in which the infant reaches age one. Revised: 02/03/16 Update # 16-03