Getting and Keeping Health Coverage for

Low-Income Californians:
A Guide for Advocates
March 2016

Jen Flory, Elizabeth Landsberg, Shirley Sanematsu,

and Mona Tawatao

Made Possible With Support From

Table of Contents
Overview of this Guide

Introduction to Part I: Eligibility Criteria At-A-Glance

A. Citizenship and Immigration Status

1. Mixed Status Families

B. Residency

C. Household and Income Requirements

1. Income Threshold and Income Counting

2. Household Determination

D. Age

E. Incarceration

10

F. Other Health Coverage

10

G. Tax Filing Status

11

H. Assets or Resources

11

I. Insurance Affordability Programs at a Glance

13

Chapter 1: Overarching Eligibility Issues for Medi-Cal

15

A. Citizenship and Immigration Status

16

1. Immigrants Eligible for Full-scope Medi-Cal

16

a. Qualified Immigrants

16

b. Lawfully Present and PRUCOL

20

2. Restricted Scope Medi-Cal

21

a. Services Covered Under Restricted Medi-Cal

22

b. Additional Programs Available Regardless of Immigration

23

Status
B. Incarceration/Institutionalization

24

C. Residency

26

Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

D. Other Health Coverage

27

E. Tax Filing Status

28

F. The Medi-Cal Hierarchy

28

Chapter 2. MAGI Medi-Cal Programs

30

A. Constructing Households

31

1. Tax Filer Rules

32

2. Non-Filer Rules

33

3. Counting Households with a Pregnant Woman

34

B. Counting Income

34

C. MAGI Medi-Cal Programs

36

1. Expansion Adults

36

2. Parents and Caretaker Relatives

41

3. Pregnant Women

44

a. MAGI Medi-Cal Programs for Pregnant Women

44

b. Medi-Cal Access Program (MCAP) for Pregnant Women and

49

Newborns up to Age 2
4. Children: MAGI Medi-Cal, the Targeted Low-Income Childrens Program,

54

and MCAP Infants and Babies

a. Infants: 0 to 1 year old

57

b. Children: Ages 1 to 6

58

c. Children: Ages 6 to 19

59

Chapter 3. Non-MAGI Medi-Cal

62

A. Non-MAGI Household and Income

64

B. Full-Scope Non-MAGI Medi-Cal for Seniors and Individuals with Disabilities

65

65

1. Categorically Linked Medi-Cal Based on Disability

a. Automatic Medi-Cal for Individuals Receiving Supplemental Security

65

Income (SSI-b. linked Medi-Cal)

b. SSI 1619(b) Medi-Cal for Individuals who Lost SSI Because of Earnings

66

from Work

2. Severely-Impaired Working Individual (SIWI) Program

68

3. Pickle Program

69

4. Disabled Adult Child (DAC) Medi-Cal

71

5. Disabled Widow/Widower Programs

74

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

6. Aged and Disabled Federal Poverty Level (A&D FPL) and Blind Federal

75

Poverty Level (Blind FPL) Programs

a. Special Rules for A&D FPL and Blind FPL Programs

82

7. 250% Working Disabled Program (250% WDP)

83

8. Aged, Blind and Disabled Medically Need (ABD-MN): Free and Share of

90

Cost
C. Full-Scope Non-MAGI Medi-Cal for Children and Families

98

1. Automatic Eligibility Due to Receipt of Government Benefits

99

2. Children in Foster Care

100

3. Former Foster Youth Under Age 18 and Not Living with their Parents

102

4. Former Foster Youth 18 and Older

102

5. Transitional Medi-Cal (TMC)

104

6. Continuous Eligibility for Children

106

7. Deemed Eligibility for Newborns

107

8. Aid for Families with Dependent Children Medically Needy

108

9. Medically Indigent

110

D. Limited Scope Medi-Cal Programs for Children

111

1. Minor Consent

111

2. Income Disregard Program for Pregnant Girls under Age 21

112

3. The Child Health and Disability Prevention (CHDP) Program

113

E. Medi-Cal Special Treatment Programs

114

1. Breast and Cervical Cancer Treatment Programs

114

2. Tuberculosis Program

116

3. Kidney Dialysis and Parenteral Hyperalimentation and Related Services

117

F. Medicare Savings Programs (MSPs)

119

1. Qualified Medicare Beneficiary (QMB or Quimby) Program

121

2. Specified Low-Income Medicare Beneficiaries (SLMB) Program

122

3. Qualified Individual (QI) Program

123

4. Qualified Disabled and Working Individual (QDWI) Program

124

G. Refugee Medical Assistance

125

Chapter 4. Covered California

128

A. Qualified Health Plans

131

1. Essential Health Benefits

131

2. Standard Benefit Design

132

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

B. Eligibility to Purchase Coverage Through Covered California

135

1. Citizenship and Immigration Status

135

2. Incarceration

138

3. Residency

139

4. Age

140

C. Eligibility for Financial Assistance

1. Lack of Minimum Essential Coverage

140
141

a. Months of Partial Coverage

143

b. Eligible But Not Enrolled

144

c. Special Rules Regarding Employer Coverage

145

i. Affordability and Value of Other Coverage

145

ii. Family Glitch

146

iii. The Enrolled Employee Exception

146

iv. COBRA

147

2. Income Threshold for Financial Assistance

a. Exceptions to the Lower Limit of Eligibility: Individuals Below

147
148

100%FPL
b. Income Counting: Modified Adjusted Gross Income (MAGI)

148

Methodology
i. Household Size and Members

150

ii. Children

150

iii. Special Consideration for Pregnancy and Newborns

151

iv. Qualifying Relative Dependents

151

v. Spouses

152

vi. Family Members Who are Not Lawfully Present

153

3. Assets

153

4. Tax Filing Status

153

a. Must File Taxes for the Year that Premium Tax Credits are

153

Received
b. Married Couples Must File a Joint Income Tax Return

154

i. Head of Household Exception

155

ii. Domestic Violence and Spousal Abandonment Exception

155

c. Individuals who are Dependents Cannot Themselves Take Premium

156

Tax Credits
5. Enrollment in a Covered California Plan

156

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

D. Calculating Premium Tax Credits

157

1. Second Lowest Cost Silver Plan The Benchmark Premium

157

2. Required Contribution Percentage

158

E. Premium Tax Credit Reconciliation

160

F. Cost-sharing Reductions

162

Introduction to Part II: Getting and Keeping Health Coverage

165

A. Application Channels

165

B. Verification Requirements

166

C. Starting Coverage

166

D. Plan Selection

167

E. Reporting Changes

167

F. Annual Renewal

167

G. Appeals

168

Chapter 5. Getting Onto Coverage

171

A. Applying for Medi-Cal, Covered California, and the Medi-Cal Access Program

174

1. Single Application, Multiple Application Pathways, No Wrong Door

174

a. Applying Online

176

b. Applying In-Person: County Offices and Community Partners

177

c. Applying by Phone: Covered California Service Center and

179

Counties
d. Applying by Mail: The Single, Streamlined Paper Application
2. Expedited Coverage Pathways

179
180

a. Acceleration Enrollment (AE)

180

b. Deemed Eligible (DE) Infants

181

c. Hospital Presumptive Eligibility

182

d. Presumptive Eligibility (PE) for Pregnant Women

184

e. CHDP Gateway

185

f. Accelerated Eligibility (AE) for Federal Breast and Cervical Cancer

187

Treatment Program (BCCTP)

g. Express Lane Enrollment (ELE)

189

h. Children in Foster Care

190

i. Former Foster Youth

190

j. Minor Consent Medi-Cal

192

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

k. Tuberculosis (TB) Program

3. Medi-Cal Connections with Public Benefits Programs

194
194

a. Programs Linked to Medi-Cal

194

b. Joint Application for health coverage and public benefits

195

4. Application Process and Eligibility for Inmates

B. Verifying Application Information
1. Overview of Process and Requirements

195
196
196

a. Medi-Cal

196

b. Medi-Cal Access Program

197

c. Covered California

198

2. Verification of Eligibility Criteria

199

a. Proving Identity

199

b. Citizenship and Immigration Status

201

i. Proof of Citizenship

201

ii. Proof of Lawful Immigration Status

202

iii. Resolving Citizenship or Immigration Inconsistencies

202

c. Incarceration

205

d. California State Residency

205

e. Income and Household Size

206

f. Pregnancy

208

g. Assets

208

h. Minimum Essential Coverage/Employer-Sponsored Coverage/

208

Other Coverage
C. When Coverage Starts

210

1. Medi-Cal

211

a. Retroactive Medi-Cal

211

b. Expedited Programs

212

2. Covered California

212

a. Covered California Open Enrollment

212

b. Covered California Special Enrollment

213

c. Covered California Coverage Effective Dates

216

3. MCAP
D. Plan Selection

218
218

1. Picking a Medi-Cal Plan

219

2. Picking a Covered California Plan

220

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

3. Picking an MCAP Plan

221

Chapter 6. Staying On

222

A. How to Keep Coverage

225

1. Changes in Circumstances
a. Medi-Cal

226
226

i. Beneficiary Obligation to Report

226

ii. Periodic Data Review

227

iii. Redetermination of Eligibility

227

iv. Relationship with Other Public Assistance Programs

230

b. Covered California

232

i. Enrollee Obligation to Report

232

ii. Semi-annual Data Review

233

iii. Additional Rules Regarding Redetermination Outcomes Due

234

to Changes in Circumstances
c. Medi-Cal Access Program (MCAP)

235
235

2. Moving
a. Medi-Cal and Inter-County Transfers (ICTs)

235

i. The ICT Process

236

ii. Accessing Care during the ICT Process

238

b. Covered California: Inter-Regional Moves and Choosing a New

239

Health Plan
i. Choosing a New Health Plan Due to a Move

239

ii. Avoiding Gaps in Coverage

239

3. Annual Renewal or Redetermination

a. Medi-Cal

240
240

i. Process for MAGI beneficiaries

241

ii. Process for Non-MAGI Beneficiaries

244

iii. Process for Households that Have Both MAGI and Non-

249

MAGI Members
iv. SB 87 and Medi-Cal Eligibility Reviews

249

v. 90 Day Right to Cure or Reinstate Medi-Cal after

251

Termination.
vi. Process When There is a Loss of Contact

251

vii. Special Processes for Certain Categories of Medi-Cal

252

Beneficaries

Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates
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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

1) Former Foster Youth up to Age 26

252

2) Mega Mandatory Groups

253

3) Deemed Eligible (DE) Infants

254

4) Foster Children Returning Home

254

5) Minor Consent

255

6) Transitional Medi-Cal

255

7) Breast & Cervical Cancer Treatment Programs

256

8) Refugee Medical Assistance

257

b. Covered California

257

i. Open Enrollment

258

ii. Notice Requirements

258

iii. Redetermination for Financial Assistance

260

c. Redetermination for Mixed Coverage Families

265

d. Redetermination for MCAP

267

B. Due Process Rights

1. Medi-Cal Eligibility Appeals

267
268

a. Notice: Content and Timing Requirements

268

b. Requesting a Fair Hearing

270

c. Expedited Hearings

272

d. Retaining Benefits During the Fair Hearing Process Aid Paid

273

Pending
e. Informal Resolution

274

f. Dismissals

275

g. Setting and Notice of Hearing; Position Statement

276

h. The Fair Hearing

277

i. After the Fair Hearing

279

2. Covered California Eligibility Appeals

280

a. Notice: Content and Time Requirements

282

b. Request for Hearing

283

c. Expedited Appeals

285

d. Eligibility Pending Appeal Continuing Enrollment

286

e. Informal Resolution

287

f. Notification of Hearing and Position Statement

289

g. The Fair Hearing

290

h. Hearing Decision and Other Post-Hearing Processes

291

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

3. Dual Agency Appeals

293

a. Shared Appeals Entity

293

b. Informal Resolution Process

294

c. The Fair Hearing

294

4. Medi-Cal Access Program (MCAP) Eligibility Appeals

C. Moving Between Programs

295
296

1. Covered California to Medi-Cal

297

2. Medi-Cal to Covered California

299

Introduction to Part III: Health Care Services for the Remaining Uninsured and

301

Underinsured
Chapter 7: Counties Legal Obligation to Provide Care to Remaining Uninsured

304

Residents
A. Financial eligibility criteria

306

B. Cost-Sharing

310

C. Timing

311

D. Residency

312

E. Programmatic Eligibility

314

F. Recouping Expenses

315

G. Scope of Services

316

Chapter 8: Options for Hospital Bills

317

A. The Hospital Fair Pricing Act

318

1. Bills that are Eligible for Financial Assistance

318

2. Charity Care and Discount Payment Plans

319

3. Minimum Standards for Financial Eligibility

319

4. Financial Assistance Notification Requirements

320

a. The Written Policy

321

b. Finding Hospital Financial Assistance Policies

321

c. Requirements for Emergency Physicians

322

5. Applying for a Discount

322

6. Reasonable Payment Plans

324

7. Collection Practices

325

B. New IRS Regulations for Non-Profit Hospitals on Hospital Financial Assistance

327

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Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates

List of Common Acronyms

329

Glossary

334

Appendices
A. 2016 Health Coverage Income Guidelines

350

B. Immigration Barriers to Applying for Health Coverage Programs

351

C. Comparison of Covered CA and Medi-Cal Hearing Processes

354

D. Where to Go for Help - A Resource List

357

E. Useful Links

359

Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates
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