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Legal Resources | Code of Regulations, Title 10 |  T10  2699.6600  

Chapter 5.8. Managed Risk Medical Insurance Board Healthy Families Program. Eligibility, Application, and Enrollment. Application.   

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(a) To apply for the program:

(1) An applicant shall submit all information, documentation, and declarations required in subsection (c) of this section.

(2) Payment in full of the following arrears, incurred within the prior twelve (12) months, by the applicant is required prior to enrollment of a person under age 19:

(A) Family child contributions owed on behalf of any person under age 19 for whom the same applicant previously applied;

(B) Family child contributions owed on behalf of a person under age 19 for whom the applicant did not previously apply but for whom the applicant is currently requesting coverage if the applicant:

1. Is the parent of the person under age 19 for whom premiums are owed; and

2. Lived in the same home as the person under age 19 when the premiums were incurred.

(3) Payment in full of the following arrears, incurred within the prior twelve (12) months, by the applicant is required prior to enrollment of a person age 19 or over:

(A) Family contributions owed on behalf of any person for whom the same applicant previously applied;

(B) Family child contributions owed on behalf of a person under age 19 for whom the applicant did not previously apply but for whom the applicant is currently requesting coverage if the applicant:

1. Is the parent of the person under age 19 for whom premiums are owed; and

2. Lived in the same home as the person under age 19 when the premiums were incurred.

(C) Family parent contributions owed on behalf of a person for whom the applicant is requesting coverage for coverage provided on or after the person's 19th birthday.

(4) The program application, entitled "Family Health Coverage Mail-In Application, for Medi-Cal and Healthy Families" (MC321 HFP, 4/06), is hereby incorporated by reference. Alternatively, the program shall utilize the on-line application submitted electronically via the internet and the school lunch application and any supplemental forms received pursuant to Section 14005.41 of the Welfare and Institutions Code to make an eligibility determination.

(b) The applicant shall sign and date the following declaration: I declare under penalty of perjury under the laws of the State of California that the answers I have given in this Application and the documents given are correct and true to the best of my knowledge and belief. I declare that I have read and understand the Application Instructions, the declarations, and all information printed on this Application.

(c)(1) The application shall contain the following:

(A) The applicant's full name.

(B) The applicant's date of birth.

(C) The applicant's primary written and oral language.

(D) The home and mailing address for the applicant and for all persons for whom application is being made, the applicant's county of residence and phone number(s), and the applicant's e-mail address (optional).

(E) An indication of whether the applicant is over the age of 18 years and applying on behalf of a child or children, and/or on behalf of a child-linked adult. An indication of whether the applicant is an 18 year old applying on his or her own behalf; the applicant is an emancipated minor applying on his or her own behalf; the applicant is a minor who is not living in the home of a parent, legal guardian, caretaker relative, foster parent, or stepparent and is applying on his or her own behalf; or the applicant is a minor who is applying on behalf of his or her child.

(F) For each person for whom the applicant is applying, the following information is requested:

1. name (first, middle and last) including full birth name if different (not required for a child not yet born)

2. marital status and spouse's name

3. birth date (not required for a child not yet born)

4. birth place (not required for a child not yet born)

5. mother's first and last name and whether living in the child's household (optional for a person age 19 or over)

6. father's first and last name if living in the child's household (optional for a person age 19 or over)

7. an indication of whether the mother and father are deceased or disabled (optional for a person age 19 or over)

8. gender (not required for a child not yet born)

9. Social Security Number (optional)

10. ethnicity (optional unless the person is an American Indian),

11. relationship to applicant.

12. if the person lives away from home (optional for a person age 19 or over)

13. if the person is going to school

14. if the person has a physical, mental or emotional disability

15. if any person in the home is pregnant and if so, the expected due date

(G) A declaration that the applicant is applying to enroll in the program all of the applicant's eligible children who are not already enrolled in the program, unless the applicant is applying only on his or her own behalf.

(H) An identification of individuals living together in the home and their relationships. If an individual is pregnant, it should be indicated, along with the expected due date.

(I) A list of family members identified in (F) and (H) above, who live in the home and who had income in the previous or current calendar year.

1. If the applicant is a parent or stepparent, an 18 year old applying on their own behalf, a child-linked adult applying on his or her own behalf or that of another child-linked adult or a minor applying on his or her own behalf or on behalf of his or her child, for the household of each person applied for, the first, middle initial, last name, gender and date of birth of all family members living in the household, each person's relationship to the person applied for and their monthly income.

2. If the applicant is applying as a foster parent, caretaker relative, or legal guardian applying only on behalf of an 18 year old or a child, a statement of the monthly income of each person applied for, for whom they are a foster parent, caretaker relative, or legal guardian.

3. If the person for whom application is being made is a qualified alien with an affidavit of support pursuant to section 213A of the Immigration and Naturalization Act, the calculation of household income must include the sponsor's income as set forth in Section 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), unless the person is eligible pursuant to Insurance Code Section 12693.76.

(J) Beginning one year after the parental coverage start date, for each child-linked adult for whom application is being made, an indication of his or her qualifying event as defined in Section 2699.6500.

(K) Documentation of the total monthly gross household income for either the previous or current calendar year. For each person listed pursuant to subsections (F) and (H) above, provide social security number (optional) and documentation for each source of income. Such documentation shall be provided for the previous or current year as indicated below:

1. For the previous calendar year:

a. Federal tax return. If self-employed, a schedule C must be included. If a person with reported income on the federal tax return is a step-parent, the step-parent's W-2 form is required to determine the amount of income associated with the financially responsible parent of the child being applied for.

b. All of the following that are applicable and that reflect the current benefit amount: copies of award letters, checks, bank statements, passbooks, or internal revenue service (IRS) 1099 forms showing the amount of Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability workers' compensation, unemployment benefits, child support, alimony spousal support, pensions and retirement benefits, loans to meet personal needs, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings, dividends, or interest income.

2. For the current calendar year:

a. Paystub or unemployment stub showing gross income for a period ending within 45 days of the date the program receives the document.

b. A letter from the person's current employer. The letter shall be dated and written on the employer's letterhead, and shall include the following:

i. The employee's name.

ii. The employer's business name, business address, and phone number.

iii. A statement of the person's current gross monthly income for a period ending within 45 days of the date the program receives the document.

iv. A statement that the information presented is true and correct to the best of the signer's knowledge.

v. A signature by someone authorized to sign such letters by the employer. The signer shall include his or her position name or job title and shall not be the person whose income is being disclosed.

c. If self employed, a profit and loss statement for the most recent three (3) month period prior to the date the program receives the document. A profit and loss statement must include the following:

i. Date.

ii. Name, address, and telephone number of the business.

iii. Gross income, gross expenses, and net profit itemized on a monthly basis.

iv. A statement on the profit and loss, signed by the person who earned the income, which states, "the information provided is true and correct."

d. A letter or Notice of Action from the County Welfare Office issued within the last two (2) months that includes:

i. For each person for whom application is being made, a statement that the person is eligible for share-of-cost Medi-Cal,

ii. A determination of total monthly household income and monthly household income after income deductions as defined in Section 2699.6500, and

iii. A determination of the number of family members living in the household.

e. All of the following that are applicable and that reflect the current benefit amount: copies of award letters, checks, bank statements, or passbooks showing the amount of Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability workers' compensation, unemployment benefits, child support, alimony, spousal support, pensions and retirement benefits, loans to meet personal needs, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings, dividends, or interest income for the previous month.

3. If documentation pursuant to 1. or 2. cannot be provided, an affidavit of income written by hand by the recipient of the income. If the individual who receives the income is unable to write the affidavit by hand because of physical or literacy limitations, the individual will sign an affidavit written on his or her behalf with a mark (unless physically incapable) and include the printed name and signature of a witness. The affidavit of income shall include the following:

a. A statement of the amount and frequency of the income received,

b. A declaration that the individual cannot provide other documentation of his or her income at the time of application to the program and that the information provided is true and correct to the best of the individual's knowledge and belief,

c. An acknowledgment that the individual understands that the information contained in his or her affidavit may be subject to a verification by the State, and

d. The signature of the individual providing the affidavit of income and the date of signature.

(L) The name of each family member living in the home who pays court ordered child support, court ordered alimony, or health insurance and the monthly amount paid. The name and age of each person for whom payments are made for child care and/or disabled dependent care by a family member living in the home and the monthly amount paid. Documentation of court ordered child support and/or alimony paid, health insurance paid, and child care and/or disabled dependent care expenses paid. Documentation includes copies of court orders, cancelled checks, receipts, statements from the District Attorney's Family Support Division or other equivalent document.

(M) A declaration that each person for whom application is being made is not eligible for Part A and Part B of Medicare.

(N) A declaration that each person for whom application is being made is a resident of the State of California pursuant to Section 244 of the Government Code; or is physically present in California and entered the state with a job commitment or to seek employment.

(O) A declaration that the applicant will notify the program within 30 days of any change of home or mailing address of any person applied for who is accepted into the program and any change in the applicant's home or mailing address.

(P) A declaration that the applicant and each person for whom application is being made will abide by the rules of participation of the program.

(Q) A declaration that the applicant and each person for whom application is being made will abide by the rules and adhere to the policies and procedures, including dispute resolution processes, of any participating plan in which such persons are enrolled.

(R) For each person for whom application is being made, indicate current employer sponsored health coverage or employer sponsored health coverage that was terminated in the last three months, including the reason for and date of the termination.

(S) For each person for whom application is being made, the applicant's declaration that the person is:

1. a citizen or national of the United States, or

2. a qualified alien who entered the United States prior to August 22, 1996 or who entered on or after August 22, 1996 and meets one of the criteria listed in Subsection 2699.6607(e)(2)(B), or

3. a qualified alien who does not meet the criteria specified in subsection (S)2. above.

(T) For each declaration made pursuant to (S), documentation of the individual's status. If documentation is unavailable at the time of application, persons declaring a status listed under subsection (S) above may submit documentation within two months from the date of enrollment. If any person for whom application is being made was previously disenrolled pursuant to Section 2699.6611(a)(3), documentation for that person shall be submitted with the application.

(U) A declaration that each person for whom application is being made is not eligible for any California Public Employees Retirement System Health Benefits Program(s) or is eligible for a California Public Employees Retirement Health Benefits Program but the employer contribution for dependent(s) is less than $10.

(V) A declaration that each person for whom application is being made is not an inmate in a public correctional institution, or a patient in an institution for mental illness.

(W) A declaration that the applicant gives permission for the program to verify family income, health coverage, immigration status of each person for whom application is being made, California residence and other facts stated in the application.

(X) For each person for whom application is being made, an indication of whether the person has other health, dental or vision insurance.

(Y) An indication of whether anyone has filed a lawsuit because of an accident or injury on behalf of any person for whom application is being made.

(Z) An indication of whether the applicant wants to apply for Medi-Cal coverage for any unpaid medical expenses in the last three months prior to application for any person for whom application is being made.

(AA) The applicant shall provide all of the following:

1. A declaration that the applicant has reviewed the benefits offered by the participating health, dental and vision plans.

2. A declaration that the applicant agrees to pay the required family contribution for a period of six months, unless the applicant has a family contribution sponsor.

(BB) The applicant may provide the following optional information:

1. The applicant's choice of participating health, dental and/or vision plans.

a.i. In any geographic region or portion thereof, the program may designate one or more participating dental plans with the lowest per-subscriber costs to the program. For purposes of this section, "designated dental plan" means a participating dental plan that the program has designated in accordance with this section.

ii. Except as otherwise provided in this section, designated dental plans, where available, shall be the only available dental plans for a household where no subscriber has at any time been enrolled in the program for two consecutive years following the subscriber's effective date.

b. An applicant may choose from all available participating dental plans for the household and shall not be limited to designated dental plans in the following circumstances:

i. There is no designated dental plan in the area where the subscribers reside.

ii. (A) On November 1, 2009, one or more subscribers in the household were enrolled in the program since before November 1, 2009; and (B) at all times after November 1, 2009, there has been at least one subscriber in the household.

iii. At least one subscriber in the household currently is enrolled in a participating dental plan that is not a designated dental plan. This exception shall apply even if (A) the subscribers move to an area where there is a designated dental plan; (B) the program makes a designated dental plan available in the area where the subscribers reside; or (C) the applicant must make a new choice of dental plan because the dental plan in which the subscribers were enrolled no longer is available.

2. The applicant's choice of primary care provider/clinic and provider/clinic code, and dentist/clinic and dentist/clinic code for the person(s) for whom application is being made.

3. An indication of whether there is more than one car in the children's household.

4. An indication of whether there is more than $3,150 cash in bank accounts in the children's household.

5. An indication if the applicant does not want the application reviewed for eligibility for Medi-Cal or the Program.

(CC) If assistance in completing the application was provided by an eligible individual, a statement by the applicant that such assistance was provided.

(DD) If applicable, a declaration that the applicant is a migratory worker or seasonal worker as defined in Section 2699.6500.

(EE) If applicable, the applicant's signed authorization that the program may release information over the telephone about the application status of the individual(s) applied for by the applicant to a representative of the enrollment entity designated by the applicant on the application. This permission will end on the date the program mails the results of the eligibility determination on this application.

(FF) If the applicant received assistance from a certified application assistant, the applicant's signed authorization (if applicable) that the program may release information notifying the entity with whom the certified application assistant is affiliated of the applicant's Annual Eligibility Review date.

(GG) If an applicant or the person for whom application is being made is American Indian or Alaska Native, acceptable documentation must be submitted to exempt the applicant from family contribution payments and benefit copayments. The exemption from family contributions and benefit copayments shall occur after receipt of such documentation. Notwithstanding the previous sentence, the exemption from family contributions will begin on the date of enrollment and continue for two months pending the receipt of acceptable documentation. If acceptable documentation is not received at the end of the two month exemption period, the appropriate family contribution will be assessed pursuant to Subsection 2699.6813(a). The applicant must indicate on the application that he or she is requesting a waiver of the family contributions. Acceptable documentation for the applicant or the child includes:

1. An American Indian or Alaskan Native enrollment document from a federally recognized tribe, or

2. A Certificate Degree of Indian Blood (CDIB) from the Bureau of Indian Affairs, or

3. A letter of Indian heritage from an Indian Health Service supported facility operating in the State of California.

(HH) An indication of how the applicant learned about Medi-Cal and the program.

(II) An indication whether the applicant would like information sent to them regarding the Child Health and Disability Prevention Program (CHDP) for children and youth or the Women, Infants and Children (WIC) program.

(2) The Social Security numbers and other personal information are needed for identification and administrative purposes.

(d) For children referred pursuant to Section 14005.41 of the Welfare and Institutions Code, the program shall use the following to make an eligibility determination:

(1) For each child for whom the applicant is applying, the child's school lunch application forwarded pursuant to Section 49557.2 of the Education Code and Section 14005.41 of the Welfare and Institutions Code; and

(2) Supplemental Form for Express Enrollment Applicants (MC 368 (06/05)); and

(3) A letter or Notice of Action from the County Welfare Office issued within the last two (2) months that includes:

(A) For each person for whom application is being made, a statement that the person is eligible for share-of-cost Medi-Cal; and

(B) A determination of total monthly household income and monthly household income after income deductions as defined in Section 2699.6500; and

(C) A determination of the number of family members living in the household; and

(4) Any additional information requested by the program pursuant to Subsection 2699.6600(c)(1)(C), (F)15., (G), (M)-(Q), (U)-(W), (AA), (BB)1.-2., (DD), (GG).

Authority cited:

Insurance Code 12693.21

Insurance Code 12693.22

Insurance Code 12693.75

Insurance Code 12693.755

Welfare and Institutions Code 14005.41

Reference:

Insurance Code 12693.02

Insurance Code 12693.21

Insurance Code 12693.22

Insurance Code 12693.43

Insurance Code 12693.46

Insurance Code 12693.70

Insurance Code 12693.71

Insurance Code 12693.73

Insurance Code 12693.74

Insurance Code 12693.75

Insurance Code 12693.755

(Amended by Register 2010, No. 24.)