Medi-Cal Handbook page (b)

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1 Medi-Cal Handbook page Effective January 1, 2014, the Affordable Care Act (ACA) expanded eligibility and enrollment simplification for several coverage groups, including Medi-Cal (MC). As of 1/1/2014 new MC applicants are no longer evaluated for MC eligibility; however, recipients enrolled in 1931b MC by 12/31/2013 remained in their current MC aid type until their next MC redetermination (RD). At MC RD they will be re-evaluated for MC under the new expanded MC rules. is expected to be phased out in Background The Personal Responsibility and Work Opportunity Act (PRWORA) of 1996 (Welfare Reform) eliminated the AFDC program and created the new TANF program. It also established the Section Medi-Cal program which provides zero share-of-cost Medi-Cal to families who would have been eligible for cash assistance under the former AFDC rules which were in effect as of July 16, Section 161 of Assembly Bill 1542 established the California Work Opportunity and Responsibility to Kids (CalWORKs) program which was implemented 1/1/98. The law provides that to the extent that federal financial participation is available, the Department of Health Services (DHS) shall extend eligibility for Medi-Cal to all recipients of aid under CalWORKs. Section Medi-Cal was effective 1/1/98. Due to the many eligibility requirements, procedures and MEDS programming that had to be developed prior to implementation, the state did not issue instructions until 11/98. Santa Clara County implemented the program for new applications in 2/99. Senate Bill (SB) 708, chaptered on 7/22/99, raises the income limits for the Section program to 100% of the Federal Poverty Level (FPL). The MBSAC income limit can still be used for RECIPIENTS when it is more advantageous. The effective date for this change is 3/1/00. Update # Revised: 10/14/14

2 page 34-2 Medi-Cal Handbook 34.2 Section General Rules The general Section rules are as follows: 1. CalWORKs recipients automatically receive Medi-Cal under Section. This is called cash-based Section. 2. Families may apply for Section Only either because they do not want to apply for CalWORKs or they are not eligible for CalWORKs. 3. A family may be ineligible for CalWORKs and still be eligible for Section because of certain less restrictive AFDC rules that do not apply to CalWORKs but which continue to apply to Section Medi-Cal. 4. Family members who are sanctioned from CalWORKs (i.e. time limits, work requirements) or are ineligible for CalWORKs (undocumented immigrant) may be eligible for Section. 5. Families with members whose income is counted by CalWORKs that would NOT have been counted in the former AFDC program may qualify for Section Medi-Cal. 6. Otherwise eligible aliens who do not have satisfactory immigration status may be eligible under Section for restricted benefits (emergency and pregnancy-related services only). 7. Personal property rules are similar to the Food Stamp property rules. 8. In general, real property is determined, defined, counted and valued in accordance with the July 16, 1996 AFDC rules. 9. Persons applying for Section must first meet residency, age, deprivation and family requirements. 10. Sneede class members of a Section MFBU who do not qualify for Section may qualify for Section after a Sneede evaluation is done. Other MFBU members who do not qualify for Section eligibility must be evaluated for AFDC-MN eligibility. Revised: 10/14/14 Update #

3 Medi-Cal Handbook page Definitions Applicant A person/family who submitted an application for Medi-Cal AND who has not received Section, separately or as a CalWORKs recipient, in any ONE of the four months prior to the month of application. Applicants must pass the 100% FPL TEST. (NOTE: The additional 50% Deduction used in the MBSAC TEST does not apply to the 100% FPL TEST.) Note: If no family member received CalWORKs or Section in ONE of the four months prior to the month of application, the family must pass the 100% FPL TEST. Once the 100% TEST is passed as an APPLICANT, the family is awarded RECIPIENT status. A RECIPIENT must pass either the 100% FPL TEST or the MBSAC TEST to remain financially eligible Disability-Based Income (DI) The Section 100% FPL and MBSAC TEST treat the following two types of unearned income as Disability-Based Income and allows a SPECIAL DEDUCTION of $240: Disability benefits from the Social Security Administration (RSDI), and Private disability benefits. (Private disability benefits paid to a covered disabled individual by his/her insurer under a disability insurance plan which the individual purchased through premiums.) [Refer to Section Income Deductions, page 34-40] Note: Social Security Survivor s and Retirement benefits are NOT considered Disability-Based income. Update # Revised: 10/14/14

4 page 34-4 Medi-Cal Handbook Note: If any part of the Railroad Retirement (RR) pension or the Veteran s (VA) benefits is based on disability, then the full amount is treated as disability-based income and must be allowed the $240 income deduction for both Section applicants and recipients Earned Income Section treats the following types of income as earned income: Earnings from a job, Temporary Workman s Compensation (TWC), and State Disability Insurance Payments (SDI) Recipient A recipient is a person/family who has received CalWORKs or Section in at least ONE of the four months prior to the month of application or case review. When a family member is added to a recipient case, he/she is treated as a RECIPIENT for purposes of evaluating his/her income. Note: RECIPIENTS must pass either the 100% FPL TEST or the MBSAC TEST to remain financially eligible for the Section program Responsible Relative A responsible relative is one who is financially responsible for someone else. Consistent with regular Medi-Cal rules, Section defines financial responsibility as: Spouse for spouse, and Parent for Child. Revised: 10/14/14 Update #

5 Medi-Cal Handbook page Forms The Section forms used for manual computations are: Form Number SC 1931 A SC 1931 B SC 1931 C SC V SC P Form Name Section Review Worksheet Section - 100% FPL TEST / MBSAC TEST Income Determination Budget Worksheet Section - MBSAC TEST Continuation Budget Worksheet for 3 or More Wage Earners Vehicle Determination Work Sheet for Section Property Reserve Worksheet-Section Program NOTE: The 100% FPL TEST and the MBSAC TEST use different income deductions. EWs must use the correct side of the SC. APPLICANTS must pass the 100% FPL TEST. RECIPIENTS must pass either the 100% FPL TEST or the MBSAC TEST. The Section - Sneede forms used in manual computations are: Form Number MC 175-3I.2A MC 175-3I.2R MC 324 Form Name Section Sneede v. Kizer Net Nonexempt Income Determination and Mini-Budget Unit (MBU) Determination - 100% FPL TEST Section Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination - MBSAC TEST Section Group Sneede v. Kizer Property Work Sheet NOTE: The 100% FPL TEST and the MBSAC TEST use different income deductions. EWs must use the correct Sneede Income Budget Form. MC 175-3I.2A is used for the 100% TEST (APPLICANTS or RECIPIENTS) and the MC 175-3I.2R is used for the MBSAC TEST (RECIPIENTS only). Update # Revised: 10/14/14

6 page 34-6 Medi-Cal Handbook 34.5 Section Eligibility Determination When a family applies for Medi-Cal, the EW must determine whether there is Section eligibility BEFORE any other Medi-Cal determination is made. The family may not choose AFDC-MN, ABD-MN or MI Medi-Cal over Section Medi-Cal. However, persons may choose whichever program is more beneficial for them when they are eligible for other Medi-Cal programs, such as the Pickle program or Limited Service programs (e.g. TB program, QMB/SLMB/QI, Income Disregard program for pregnant women). When a family is discontinued from CalWORKs due to earnings related reasons, the EW must determine ongoing Section eligibility BEFORE a Transitional Medi-Cal (TMC) or any other Medi-Cal determination is made. Example: A family received CalWORKs for 18 months and is discontinued from CalWORKs because of increased earnings. (The PWE is not subject to the 100 hour rule for Section cash-based Medi-Cal, but his/her earnings increase makes the family ineligible). The EW evaluates the family for Section eligibility and the income does not exceed the Section income limit. The family is eligible for and must be issued Section, not Transitional Medi-Cal (TMC). The family may later qualify for TMC if Section is discontinued due to increased earnings Months Retroactive Section Medi-Cal A Medi-Cal applicant is entitled to request and be evaluated for retroactive eligibility for any month within the three-month retroactive period. The application for Retroactive Medi-Cal may be made in conjunction with, or after, the application for Medi-Cal is submitted. However, it must be submitted within one year of the month for which retroactive coverage is being requested. Revised: 10/14/14 Update #

7 Medi-Cal Handbook page General Rule When evaluating the 3-month retroactive time period for Section, the EW must determine if the household has APPLICANT or RECIPIENT status. This will determine which income test applies when determining financial eligibility. If CalWORKs or Section was received in any of the four months preceding the month being evaluated, then the retroactive month is treated under the RECIPIENT status rules. (100% FPL TEST or MBSAC TEST is used.) If CalWORKs or Section was NOT received in any of the four months preceding the month being evaluated, then the retroactive month is treated under the APPLICANT status rules. (100% FPL TEST is used.) Once the 100% FPL TEST is passed, RECIPIENT status rules apply in each successive retroactive month and in the month of application EXAMPLES EXAMPLE 1: A family applies for Section in May. They last received CalWORKs in December, which is not within four months of their application month. They have no outstanding medical bills so Retro Medi-Cal is not requested. The family has APPLICANT status and the 100% FPL TEST is used to determine eligibility for the month of May. EXAMPLE 2: A family applies for Section in may. They last received Section in December, which is not within four months of their application month. They request Retro Medi-Cal for February, March and April. The EW reviews February and sees that the family received Section in December (within the four months prior to February). Therefore, the family has RECIPIENT status and the 100% FPL TEST or MBSAC TEST is used to determine eligibility for February. If the family passes the Section 100% FPL TEST or MBSAC TEST in February, then RECIPIENT status is brought forward to March, April, May, June, etc., until there is a break-in-aid of 4 months or more. This means that the family is also entitled to RECIPIENT status in the application month of May. EXAMPLE 3: A family applies for Section in May. They last received CalWORKs in November, which is not within four months of their application month. Retro Medi-Cal is requested for April only. The EW reviews April and sees that the family did not receive CalWORKs or Section within the four months prior to April. Therefore, the family has APPLICANT status and the 100% FPL TEST applies. Update # Revised: 10/14/14

8 page 34-8 Medi-Cal Handbook If the family passes the Section 100% FPL TEST in April, then RECIPIENT status begins in May (the application month). If the family does not pass the 100% FPL TEST in April, then the family must pass the 100% FPL TEST in May in order to be determined Section eligible Late Requests for Retro Late Requests for Retroactive Coverage refers to Retro applications submitted timely, but after the original Medi-Cal application has been processed and the eligibility determination has been completed. When a Late Request for Retroactive Coverage is submitted, the EW must determine Section eligibility for the retro months. Follow the chart below to determine the appropriate actions: If Retro Section eligibility is... NOT established, Established and Section was approved when the original application was processed, Established and Section was NOT approved when the original application was processed, Then... Evaluate the family for other types of Medi-Cal. Approve Section in the appropriate Retro months. 1. Approve Section in the appropriate Retro months. 2. Do NOT redetermine Section eligibility in the month of application. 3. In the month following the month in which the request for Retro Medi-Cal was made, evaluate Section eligibility using the RECIPIENT status rules. Approve Section if either the 100% FPL TEST or the MBSAC TEST is passed. NOTE: If neither test is passed at this time, all future Section reviews are done following the standard APPLICANT/RECIPIENT rules. Example: On 12/3, a Medi-Cal application is submitted. The EW explores Retroactive Medi-Cal; however, the client indicates that he/she does NOT need it. On 12/7, the EW determines that the family is not Section eligible because they do not pass the 100% FPL TEST. AFDC-MN and FPL Medi-Cal are approved instead. Revised: 10/14/14 Update #

9 Medi-Cal Handbook page 34-9 On 4/6, the family contacts the EW to request retroactive Medi-Cal for October and November. The family passes the Section 100% FPL TEST for October. The month of November is processed under RECIPIENT status rules. Since the Medi-Cal determination for December has already been completed, the EW does not redetermine Section eligibility for December as a RECIPIENT. The original determination stands. However, the EW reviews for Section eligibility in May using the RECIPIENT status rules General Eligibility Procedures Note: Unless otherwise stated, all eligibility rules and determinations for Section follow regular Medi-Cal rules per the Medi-Cal Handbook. Step Action 1. Identify families who meet the potential Section eligibility criteria. (Residency, Age, Deprivation) 2. Review CalWIN/MEDS for type of benefits received in the last four months. 3. Determine status as APPLICANT or RECIPIENT for Section income eligibility tests. 4. Determine if family members meet the Section eligibility criteria (Residency, Age, Deprivation, Income, and Property). 5. Complete the appropriate income budget worksheet(s) when using a manual process. 6. Complete the Property Reserve Worksheet-Section [SC -P] when using a manual process. 7. If not income or property eligible and there is a Sneede class member, determine eligibility for Section Sneede. 8. If not Section Sneede eligible, determine eligibility for TMC, MN, MN Sneede, Property Waiver and Special Programs. Update # Revised: 10/14/14

10 page Medi-Cal Handbook 34.8 Section Screening Criteria All Medi-Cal applications other than ABD, LTC and Minor Consent must be evaluated for Section eligibility before any other Medi-Cal eligibility is established, including Transitional Medi-Cal (TMC). The EW must screen all cases containing AFDC-MN and MI children when: Completing the initial intake interview, Completing the annual redetermination, Revising the budget due to changes in income or circumstances, The client requests a Section determination Age A family must have at least one child under 18 years of age. Exception: The child may be 18 years old if he/she is enrolled as a full-time high school student and is expected to graduate before reaching the age of nineteen. School verification is required. EWs may use either the CSF 37 school verification form or a letter from the school on letterhead. THE SC 1302 MUST NOT BE USED FOR SECTION. A person age 18 and over, not meeting the exception above, who is living in the home with a senior parent and other siblings is: Considered an adult for Section, Not eligible for Section (unless he/she has a deprived child), An ineligible member in the Senior parent s Section MFBU, unless he/she is a parent of a deprived child who is living in the home and could apply for Section in a separate case, and the senior parent does not have care and control of the adult parent s child. Revised: 10/14/14 Update #

11 Medi-Cal Handbook page Unborn The unborn of a pregnant woman with NO other eligible children is considered a child for Section eligibility for the sole purpose of evaluating the mother s eligibility for Section in her last trimester. The unborn must have a deprivation. If the only deprived child is an unborn in the last four months of pregnancy (last trimester), the spouse or the unmarried father in the home is an ineligible member of the Section MFBU and is not eligible for Section until the child is born. The father (married or unmarried) may be eligible for the MN program. The unborn of a pregnant woman WITH other eligible children is counted in the family size when determining the Section income limit starting from the onset of pregnancy. [Refer to Pregnant Woman, page ] 34.9 Deprivation Deprivation must exist. Rules to establish deprivation includes: Deceased Parent Deprivation[50209] Deprivation of parental support or care exists if either of the child's parents is deceased. The death of a parent links the children, the remaining parent or a non-parent caretaker relative of the children Note: Client's sworn statement on the MC210 is sufficient to establish this deprivation, unless there is reason to believe that the statement is questionable. Update # Revised: 10/14/14

12 page Absent Parent (A/P) Deprivation Medi-Cal Handbook Deprivation of parental support or care exists if there is continued absence of one or both parents from the home. Deprivation of absence links the children of the absent parent, the remaining parent or the non-parent caretaker relative, including the caretaker of children receiving PA. Continued Absence Continued absence shall constitute deprivation if the absence is both: 1. Of such a nature as to interrupt, terminate or preclude the parent's providing for the children any of the following: Maintenance, or Physical care, or Guidance AND 2. Of a known or indefinite duration which would preclude the parent's planning for the present support or care of the children. Temporary Absence Deprivation does not exist when the parent is absent from the home on a temporary basis, such as for: A visit. A trip. Current employment. Seeking prospective employment. Due solely to active duty in the uniformed services of the United States. Note: Uniformed services include the Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanographic and Atmospheric Administration and Public Health Service of the United States. Revised: 10/14/14 Update #

13 Medi-Cal Handbook page Establishing A/P Deprivation Absent Parent Deprivation will be established by client's statement on the Statement of Facts unless the EW has conflicting information. In the case of conflicting information, the client's statement shall be supported by one of the following: Written statement from the absent parent. Written statement from persons with prior knowledge of the family relationship. The actions of the applicant, beneficiary or absent parent clearly indicate the physical absence of the other parent OR the interruption of or marked reduction in marital and family responsibilities. The above must be clearly documented on the [Case Comment] window in CalWIN. Other evidence that substantiates continued absence. Joint Custody Deprivation based on continued absence may be established in joint custody cases as long as the child(ren) is not living with both parents at the same time. Periods of time spent in the home of the parent who is not the caretaker parent will be considered temporary absences. [Refer to Definitions, page 60-1.] Who is Linked to A/P Deprivation The following people are linked to Medi-Cal due to A/P deprivation of the child: The child. The parent/caretaker relative in the home. Note: If the parent in the home is married, and the spouse also has children from a prior union, then the separate children of each parent and both parents are linked due to A/P deprivation. The mutual children could be eligible as MI. Update # Revised: 10/14/14

14 page Incapacitated Parent Deprivation [50211] Medi-Cal Handbook Deprivation of parental support or care exists if either of the child's parents is physically or mentally incapacitated. Incapacity provides linkage for the children of the incapacitated parent, the incapacitated parent, the second parent of the children if living in the home, and the spouse of the incapacitated person, (i.e. the stepparent of the deprived children). The physical or mental illness, defect or impairment must be EXPECTED TO LAST AT LEAST 30 DAYS AND: Reduce substantially or eliminate the parent's ability to support or care for the child, or Prevent the parent from working full-time at a job in which he/she is customarily engaged, or Prevent the parent from working a full-time job for which he/she is equipped by education, training, experience or which could be learned by on-the-job training, or Cause employers to refuse to employ the parent for work the parent could do and is willing to do because of behavioral or other disorders which interfere with the securing and maintaining of employment, or Prevent the parent from accomplishing as much on the job as a regular employee and, as a result, the parent is paid on a reduced basis, or Establish for the parent, linkage to Adult-MN as blind or disabled; or Cause the parent to be qualified for and employed in a job which is rehabilitative, therapeutic, or is in a sheltered workshop, and which is not considered to be full-time. Establishing Incapacitated Parent Deprivation Incapacitated Deprivation shall be established by one of the following: Written statement by a physician, a licensed or certified psychologist, or authorized staff member on doctor's letterhead. Completed Medical Report (MC 61) Form. Revised: 10/14/14 Update #

15 Medi-Cal Handbook page Current DDSD 221R. Receipt of RSDI, SSI/SSP or R/R Board benefits based on total and permanent disability or blindness. Receipt of SDI or Workers Compensation. Verbal statement from a physician, licensed or certified psychologist or authorized member of their staff may be accepted for 60 days, pending receipt of written verification. Document in the Maintain Case Comments window for follow-up. Use Other Conclusive Verification as the verification source. Note: A statement from a chiropractor or any other health professional not described above cannot be accepted as proof of incapacity for Medi-Cal purposes. Reminder: Incapacity must be verified prior to approval of eligibility. [Refer to Definitions, page 60-1 for further information.] Unemployed Parent Deprivation [50215] Effective November 26, 1996, U/P deprivation requires only that the PWE does not work 100 hours or more in a given month. Effective March 1, 2000, U/P deprivation requirements were expanded to include families with a PWE who works over 100 hours per month, if the family s net non-exempt EARNED income is AT or BELOW 100% Federal Poverty Limit (FPL). Effective May 1, 2001, a State Plan Amendment was approved which further expanded U/P deprivation requirements to exempt all earned income of children in the family when determining whether the PWE is unemployed even though he/she is working 100 hours or more. Rule Deprivation of parental support or care exists if a parent with whom the child lives meets the conditions of an Unemployed Parent (U/P). Conditions of an Unemployed Parent The Unemployed Parent (U/P) must be determined as the Principal Wage Earner (PWE) AND meet ONE of the following conditions for U/P deprivation to exist: Update # Revised: 10/14/14

16 page Medi-Cal Handbook 1. Is working under 100 hours per month. This includes when the PWE is: Not working, or Working less than 100 hours per month, or Employed on an intermittent basis more than 100 hours per month and the hours in excess of 100 hours are of a temporary nature. Note: Temporary nature is shown if the parent was under the 100 hour standard for the two prior calendar months and is expected to be under the standard during the next month. OR 2. The total net non-exempt EARNED income of the parents or the parent and his/her spouse is AT or BELOW 100% of the Federal Poverty Level (U/P Income Test). Principal Wage Earner (PWE) EWs must first establish which parent is the Principal Wage Earner (PWE) in order to determine if U/P deprivation exists. The PWE is the parent who has earned the greater amount of income in the 24-month period immediately preceding either: The month of application, reapplication or restoration, or The date that a family's circumstances have changed in such a way as to meet the U/P deprivation requirements. Note: If both parents qualify as the PWE and have earned an identical amount of income (or no income) in the 24-month period, the EW in consultation with the parents must designate which parent is the PWE. Once the PWE has been determined, this parent continues to be the PWE for each consecutive month, even if the other parent has earnings in the last two years. EXAMPLES Incapacitated at Time of ApplicationA family applies for Medi-Cal on December 1st and deprivation is based on the incapacity of the father. In March, the EW learns that the father is no longer incapacitated as of March 10th. A U/P Revised: 10/14/14 Update #

17 Medi-Cal Handbook page determination must be completed in March. A determination of who is the PWE begins on the date that the deprivation changed (March 10th). It is not based on the month of the original application. Unemployed Parent Becomes IncapacitatedA family is determined eligible for Medi-Cal based on U/P deprivation at the point of application. Four months later the PWE becomes incapacitated due to a broken arm. The deprivation must be changed to incapacity. However, when the incapacitated parent recovers, the deprivation is changed back to U/P. The PWE determination still exists based on the earlier U/P determination. CalWORKs U/P Case Becomes Medi-Cal Only CaseThe father is determined to be the Principal Earner (PE) in a CalWORKs U/P case. His wife begins to work and the family becomes financially ineligible for CalWORKs due to excess earnings. CalWORKS is discontinued and ongoing Medi-Cal eligibility is explored. U/P deprivation still exists and does NOT need to be reestablished since the PWE is still considered an unemployed parent. Therefore, the family is still linked to the Section program. Eligibility for Section is determined first. If the family is not eligible, TMC is explored. Reapplication for Medi-CalIf there has been more than a one month break-in-aid, the PWE must be reestablished. MC 210 S-W CalWIN determines the PWE if employment history for both parents is entered. CalWIN also determines the U/P deprivation. If the client is having an interactive interview at Intake, it is not necessary for them to complete the Vocational and Work History form (MC 210 S-W). The EW will obtain that information from the client and enter it in CalWIN. For mail-in applications, the worker can first try to obtain the employment history from the client over the phone, enter it in CalWIN and document in Maintain Case Comments window how the information was obtained. If the worker is unable to contact the client to get the information, then the MC 210 S-W must be sent to the client to gather the data for CalWIN to determine the PWE. Unless there was a break in aid or only one parent was in the home at intake and the A/P has now returned, a new PWE determination does not need to be done at redetermination. The MC 210 S-W can be used to determine: Which parent is the principal wage earner (PWE) Update # Revised: 10/14/14

18 page U/P deprivation when both parents are in the home. Medi-Cal Handbook Note: If the PWE works 100 hours or more a month, the Unemployed Parent Worksheet (MC 337) will be used to determine U/P deprivation. Only one signature is required, usually the applicant's. Determination of the PWE is not required when there is other linkage, such as absent parent. U/P Income Test U/P deprivation exists if the total net non-exempt EARNED income of the parents or the parent and his/her spouse is AT or BELOW 100% of FPL (U/P Income Test). Sneede rules do NOT apply to the U/P Income Test. The U/P Income Test applies to AFDC-MN and Section. Countable Earned Income Only the net non-exempt EARNED income of the parents or the parent and the parent s spouse is counted. Earned Income includes income received from: Employment, Earned Income In Kind State Disability Insurance (SDI), and Temporary Workers Compensation (TWC). DO NOT count the EARNED income of a parent who receives Public Assistance (PA) or Other PA or who has the option not to be aided and is not in the MFBU. DO NOT include these persons in the family size to determine 100% of FPL. Allowable Deductions The following deductions are allowed when determining net non-exempt EARNED income for U/P deprivation: $90 Standard Work Expense (SWE) $65 and 1/2 if there is an aged, blind or disabled family member in the MFBU Child Care Deduction Court-Ordered Child/Spousal Support Allocations to PA Members Allocations to Excluded Children. Revised: 10/14/14 Update #

19 Medi-Cal Handbook page Note: Health Insurance Premiums are allowable deductions for Medically Needy (MN) budget only. Procedure Follow the steps below to determine the net non-exempt income: Step Action Calculation 1. Subtract $90 from the gross non-exempt EARNINGS of the PWE and his/her spouse. (Use the $65 + 1/2 and the unused $20 rather than the $90 if there is an ABD person in the MN determination). 2. Add each person s net EARNINGS together to get the total family countable EARNED INCOME. Earnings of: PWE 2nd Adult $ - 90 = $ $ - 90 = $ Countable Earnings = $ 3. Determine total allowable deductions, including: Child Care Expenses, Court-Ordered Child/Spousal Support, Allocations to PA members, and Allocations to excluded children. $ + $ + $ + $ Total Deductions = $ 4. Subtract the allowable deductions to get the family s Total Net Non-exempt EARNED Income Step 2 - Step 3 = $ 5. Determine 100% of FPL for the appropriate family size. 100% of FPL = $ 6. Compare Line 4 to Line 5. Is the Total Net Non-Exempt EARNED Income of the Parents AT or BELOW 100% of FPL? Yes; U/P Deprivation Exists. No; No U/P Deprivation. Who is Linked to U/P Deprivation Unemployed Parent (U/P) deprivation links the: Child(ren) of the unemployed parent, Unemployed parent, and Second parent in the home. Note: The stepparent can be treated as an essential person in the Section program. [Refer to MFBUs Containing Stepparents, page ] Update # Revised: 10/14/14

20 page Medi-Cal Handbook Exception: Once Unemployed Parent (U/P) deprivation is established under the Section program, U/P deprivation continues as long as the family continues to pass either the 100% FPL TEST or the MBSAC TEST, even if the PWE works more than 100 hours per month or the parents/parent and spouse s earnings exceed 100% of FPL (U/P Income Test). [Refer to Unemployed Parent Deprivation [50215], page ] Earned income in-kind is counted when determining unemployed parent deprivation. U/P deprivation must be reestablished whenever there is a one calendar month break-in-aid. The PWE must once again meet the 100 hour rule or pass the U/P Income Test. [Refer to U/P Income Test, page ] EXAMPLE 1: If the case is already a U/P case and the PWE RECIPIENT begins to work over 100 hours, the 100-hour rule does NOT apply. The case retains the U/P deprivation. EXAMPLE 2: If the case is already a U/P case and the total net non-exempt EARNED income of the parent(s) and the parent s spouse exceeds 100% of FPL, the case retains U/P deprivation as long as the family remains income eligible (100% FPL TEST or MBSAC TEST is passed). EXAMPLE 3: When absent parent deprivation stops due to the A/P returning home, a new deprivation must be established in order to continue Section Medi-Cal. If U/P deprivation is being established, the PWE must meet the 100 hour rule or pass the U/P Income Test. (The RECIPIENT status for income tests continue to apply when determining financial eligibility.) EXAMPLE 4: When the unemployed PWE becomes incapacitated, and then changes back to U/P deprivation, the PWE does NOT need to meet the 100 hour rule or pass the U/P Income Test. (Again, the RECIPIENT status for income tests continue to apply when determining financial eligibility.) Revised: 10/14/14 Update #

21 Medi-Cal Handbook page Property The property limit for an MFBU of one or two is $3000. For each additional family member in the MFBU, add $150 to the property limit. Note: A family found to be ineligible for Section due to excess income or excess property, may qualify for regular Medi-Cal. In some situations, the applicable financial eligibility requirements for regular Medi-Cal are less restrictive Income An APPLICANT family must pass the 100% FPL TEST. A RECIPIENT family must pass either the 100% FPL TEST or the MBSAC TEST. (NOTE: The EW must use the most advantageous of the two tests.) [Refer to Section Income Limits and Tests, page ] [Refer to Chart Book, Current Section Income Limits, page 5-46.] 34.10MFBU Determination General Section MFBU Rules ALL family members are included in the Section MFBU. Family members who do not meet Section eligibility criteria (i.e. no deprivation or linkage) are treated as ineligible persons (IE) in the Section MFBU. CalWORKs, SSI, Pickle, and/or IHSS recipients are treated as excluded members in the Section MFBU. Otherwise eligible immigrants who do not have Satisfactory Immigration Status (SIS) may be eligible for restricted Section Medi-Cal benefits only. A parent is linked to Section if he/she: Update # Revised: 10/14/14

22 page Is a deprived child (as in a minor parent case), or Medi-Cal Handbook Has at least one deprived child eligible for Section or any other type of zero share-of-cost Medi-Cal (this includes, Deemed Eligibility [DE], Continuous Eligibility for Children [CEC], Federal Poverty Lever [FPL] programs), AND the parent passes other Section eligibility criteria (e.g., income, property). Example: Mom, Dad and one child apply for Medi-Cal. Mom and Dad have zero income, but the child receives $1000/month unearned income. When the Section - Sneede computation is completed, Mom and Dad pass the Section income limits, but the child does not. The child is evaluated for MN/MI and is found to have a SOC. The child is then evaluated for the appropriate FPL program. If the child is eligible for the FPL program (zero SOC Medi-Cal), Mom and Dad are eligible for Section, provided that Mom and Dad pass other Section eligibility criteria (e.g., income, property). If the child is NOT eligible for the FPL program and ends up getting Medi-Cal with a SOC, Mom and Dad are not linked nor eligible for Section Mixed Household Situations Section & MN/MI Medi-Cal When only some family members are determined eligible for Section or Section - Sneede, the remaining family members may be eligible for MN/MI Medi-Cal. Follow the rules listed below to establish the MN/MI MFBU and determine the appropriate treatment of income for each MFBU member. All persons from the original Section MFBU who are ELIGIBLE for Section are NOT included in the MN/MI MFBU. Their income and property is not counted. All persons from the original Section MFBU who are INELIGIBLE for Section are included in the MN/MI MFBU. The income of MN/MI MFBU members is treated as follows: All non-exempt income of a child in the MN/MI MFBU is counted. Revised: 10/14/14 Update #

23 Medi-Cal Handbook page If the income of an adult in the MN/MI MFBU was used to determine Section eligibility for a spouse, then none of the adult s income is used in the MN/MI determination. If the income of an adult in the MN/MI MFBU was used to determine Section eligibility for his/her child, then the income or portion of income used (parental allocation to each child eligible for Section 1931[b]) is not used again in the MN/MI determination. No income or Sneede allocation from any person eligible for Section is carried over to family members who did not pass Section and are being determined for the MN/MI program. [Refer to Income Allocation Rules - Section and MN/MI Medi-Cal, page for additional information.] Section & FPL Medi-Cal All persons included in the original Section MFBU are included in the FPL family size to determine the applicable poverty level limit. When determining the net nonexempt income of the family, count only the income of the: Child being evaluated, and Family members who are responsible relatives of that child. Example: Count the income of the parent of a child being evaluated for an FPL program. Do not count the income of a sibling or stepparent of a child being evaluated for an FPL program. The following individuals are included in the entire FPL family size but their income is not counted. An essential person who chooses not to receive Medi-Cal and only the spouse s separate children are requesting Medi-Cal. An unmarried father who does not want to be aided with his pregnant girlfriend and he has no other born children living in the home. Update # Revised: 10/14/14

24 page MFBUs Containing Stepparents Medi-Cal Handbook Stepparents may be aided as an essential person under the former Aid to Families with Dependent Children (AFDC) and the current California Work Opportunity and Responsibility to Kids (CalWORKs) program. Regular Medi-Cal rules only allow the stepparent to be linked if the spouse is incapacitated. Under Section, the stepparent must ALWAYS be included in the MFBU because he/she is financially responsible for his/her spouse, regardless of whether the stepparent wishes to be aided or not. However, Sneede rules would apply. Exception: The stepparent is not included in the Section MFBU if only the separate children of his/her spouse want Medi-Cal. Count any income/property belonging to the children applying for Medi-Cal. If the children s parent has income, allow a parental allocation, allow an allocation to the spouse and other children in the household and then, budget the balance of his/her income. The stepparent income and/or property is not counted at all. Stepparent s Non-Cooperation If the stepparent refuses to cooperate or does not wish to be aided, his/her spouse would be an ineligible member of the MFBU with her separate children. The stepparent spouse s separate children are not in any way affected by the stepparent s non-cooperation and therefore must be evaluated for Medi-Cal. If the mutual children or the stepparent s separate children wants to be aided, the stepparent must be included, otherwise there is no eligibility for either the mutual or the stepparent s separate children Excluded Child Children can be excluded from the Section MFBU regardless of whether or not they have separate income or property. The parent or caretaker must sign the Sneede v. Kizer Excluded Child Statement (MC 239 SN-3). Revised: 10/14/14 Update #

25 Medi-Cal Handbook page When a child is excluded, he/she is not included in the MFBU and his/her separate property and income are not considered when determining program eligibility. An excluded child cannot be used as the basis for deprivation/linkage. The child, however, does receive a Sneede parental allocation Pregnant Woman A pregnant woman must have a deprived child or an unborn who if born would be deprived, in order to be potentially eligible for Section. Pregnant Woman With No Other Children A pregnant woman with no other children must be in her last four months (last trimester) of pregnancy to be potentially eligible for Section Medi-Cal, if she has no other deprived children in the home. The unborn must have deprivation. These rules are consistent with the rules of the former AFDC program. Father of the Unborn in the Home With No Other Deprived Children If the father (married or unmarried) of the unborn is in the home, he is NOT eligible for Section until the unborn is born. However, the father must be included in the Section MFBU and his income and property are considered when determining Section eligibility for the pregnant woman. If the parents are NOT married, Sneede rules apply. The father (unmarried or married) of the unborn may be eligible for AFDC-MN Medi-Cal if he wants to be aided. IF... A MARRIED father wants to be aided under the MN/MI program, THEN... His income is NOT carried over to his MN MFBU because he is a financially responsible relative to his spouse and his income is used when determining his pregnant spouse s eligibility for Section. Once the baby is born, he may be added to Section with no determination IF there is no change in the family income. An UNMARRIED father wants to be aided under the MN/MI program, All of his income is counted in his MN MFBU. He may not deduct his income (used when determining Section 1931[b] eligibility for his pregnant girlfriend) from his MN MFBU. Update # Revised: 10/14/14

26 page Pregnant Woman With Other Children Medi-Cal Handbook If the pregnant woman has other deprived children, the unborn is included in the family size at the onset of pregnancy Care and Control A question of care and control is not included in any Medi-Cal applications. As part of eligibility and MFBU determination, the EW must explore care and control if an ADULT or a MINOR parent with his/her child live with a caretaker relative. A person is considered to have care and control if the person: Decides where the child attends school Deals with the school on child s educational decisions and problems Controls child s participation in extracurricular and recreational activities Arranges child s medical and dental care services Claims the child as a tax dependent Purchases and maintains the child s clothing. The chart below illustrates the importance of determining who has care and control. For Section Care and control determines who has linkage and MFBU composition. Section allows an otherwise eligible caretaker relative or a senior parent, ADULT parent and adult parent s child to ALL be aided when they reside in the same home and the senior parent has care and control of the adult parent s child. If a senior parent (with no other deprived children) has no care and control of both the MINOR parent and the minor parent s child, then the senior parent is an ineligible member of the minor parent s Section MFBU. The senior parent must then be evaluated for the MN program in an MFBU of one (similar to what would occur if the minor mother were receiving CalWORKs). For MN Program The issue of care and control of a senior parent in a three generation household does not matter if the ADULT parent is in the home. Regular Medi-Cal does not aid a caretaker relative if an ADULT parent is in the home, unless the ADULT parent s parental rights have been terminated. Care and control is not an issue for the MN program if children are under 21 and living with a senior parent. Since a senior parent is a financially responsible relative to the MINOR parent, the senior parent and the minor parent are in the same MN MFBU. The minor parent is an ineligible member of his/her child s MFBU. Revised: 10/14/14 Update #

27 Medi-Cal Handbook page Caretaker Relatives The following rules apply to caretaker relatives. MFBU Requirements A related child can provide linkage to the caretaker relative because the parent is absent from the home or for Section purposes only, the parent lives in the home but has no care and control. A caretaker relative is not required to be in the MFBU if he/she is not requesting Medi-Cal benefits for himself/herself. Caretaker relatives are not responsible for their related children. No allocation of the caretaker relative s income/property is to be made. If the caretaker relative is pregnant, aged, blind or disabled, he/she need not be included with the related child. However, he/she must be linked to a deprived child to be eligible for the Section program. If a caretaker lives with his/her spouse, the spouse may not be aided unless the spouse has other linkage (e.g., aged, blind or disabled). If the caretaker s spouse has other linkage, he/she is in his/her own MFBU.The caretaker s spouse s income and property is not counted in the caretaker s MFBU with the related child. Note: Spouse for spouse responsibility rule does not apply when a caretaker is in the MFBU with his/her related child. More Than One Non-Parent Caretaker Relative and Related Children ONLY one NON-PARENT caretaker relative may be linked to a child. If there is more than one child in the household and they are NOT siblings, each caretaker may be linked to a different child. The caretakers would be in separate budget units with their related child. Spouse for spouse responsibility rule does not apply when a caretaker is in the MFBU with his/her related child. Option to be Linked to Related Children or Own Children A caretaker relative with his/her own deprived child and a related child may choose to be linked to either his/her own child or the related child. Update # Revised: 10/14/14

28 page Medi-Cal Handbook When a caretaker relative chooses to be aided with his/her related child: The related child can provide linkage for the caretaker (i.e., if the caretaker s children have no deprivation). The caretaker s income and property is NOT counted in the caretaker s spouse/children s Section MFBU, MN or MI MFBU, except when determining Federal Poverty Level (FPL) eligibility for his/her children. A caretaker relative who is eligible for Section with a related child is not in the MFBU with other household members who are not eligible for Section unless the caretaker s spouse, other parent, or children are being evaluated for the Federal Poverty Level (FPL) programs. The chart below further enumerates different situations to clarify MFBU determinations and ONLY applies when a caretaker relative chooses to be linked with his/her related child. If the caretaker relative chooses to be linked with his/her related child AND THE CARETAKER RELATIVE... But... Then the Caretaker Relative... Is eligible for Section with a related child, Is eligible for Section, Note: The related child must be eligible for a zero share of cost (SOC) Medi-Cal program for the caretaker to be linked to Section. Is INELIGIBLE for Section, The related child is not eligible for Section, The related child is eligible for Section, Is not included in his/her spouse s and/or children s Section, MN or MI MFBU, except when determining FPL eligibility for his/her children. Is not in the related child s MN MFBU, and Is not in his/her spouse/children s MN/MI MFBU. Must be evaluated for the MN program, and Is linked to the deprived related child, and Is NOT in his/her spouse/children s Section MFBU, or Is in the same MN/MI MFBU with his/her spouse and/or children (i.e., if his/her own children not eligible for Section 1931[b]). Revised: 10/14/14 Update #

29 Medi-Cal Handbook page If the caretaker relative chooses to be linked with his/her related child AND THE CARETAKER RELATIVE... But... Then the Caretaker Relative... And the related child are BOTH INELIGIBLE for Section (even after applying the Sneede rules,) Are eligible for the MN program Is in the same MN MFBU with the related child, and The caretaker is also included in his/her spouse s and/or children s MN or MI MFBU as an ineligible member. Note: The caretaker s full income is both counted in his/her MN MFBU with the related child, AND in his/her spouse/children s MN/MI MFBU. Adult Parent with Children Living with a Caretaker Relative For Section, an adult is a person age 18 (not expected to graduate before his/her 19th birthday) or older. The Section program (consistent with the California Work Opportunity and Responsibility to Kids (CalWORKs) program) allows an otherwise eligible adult parent, adult parent s child, and a caretaker to ALL be aided when they reside in the same home. The caretaker relative must have care and control of the adult parent s child. If... A caretaker relative or a senior parent has care and control of the ADULT parent s child, A caretaker relative wishes to be aided Then... The caretaker relative or the senior parent is linked to Section. Example 1: Jane (age 19) and her son live with Jane s mother who has care and control of her son. Jane s mother is linked to Section. Example 2: Jane (age 19) and her son live with Jane s Aunt who has care and control of her son. The aunt is linked to Section. ALL (caretaker relative, adult parent, and adult parent s child) are included in one MFBU. The MFBU is under the ADULT parent s name and case serial #. Example: Same as above. Jane, her son, and her mother must be in the same MFBU. The MFBU has excess income or property, Sneede rules would apply and only the income of the ADULT parent is allocated to the child. Update # Revised: 10/14/14

30 page Medi-Cal Handbook If... The caretaker is not eligible for Section, The ADULT parent s parental rights have been terminated, Then... The caretaker is not eligible under the MN program if the ADULT parent is being aided in Section unless he/she has other linkage. Example: Jane s mother is ineligible for Section due to excess income. Jane s son cannot provide MN linkage for the senior parent/caretaker relative if Jane is being aided in Section. The ADULT parent is not included in the MFBU. Example: Same as above but Jane s parental rights have been terminated. MFBU consists of Jane s son and the senior parent. Jane, even though living in the home, is not included in the MFBU. Jane s income/property is not counted. Note: Regular Medi-Cal (MN) rules do not aid a caretaker relative if there is an adult parent (age 21 or older per MN definition) and their minor child in the home. Non-Needy Caretaker s Related Children Receiving CalWORKs A non-needy caretaker relative who receives CalWORKs for needy children may be eligible for Section Medi-Cal. The EW must evaluate that caretaker relative for Section eligibility first, before determining eligibility for any other Medi-Cal program No Caretaker Relative If a child is not living with a parent or caretaker relative, the child is not eligible for Section Medi-Cal Senior Parent/Minor Parent Cases Consistent with the AFDC and CalWORKs rules, Section considers any parent under the age of 18 living with his/her parent(s) a minor parent. Note: AFDC-MN/MI rules consider any parent under the age of 21 living with his/her parent(s) a minor parent. Revised: 10/14/14 Update #