Medi-Cal Handbook Continued Eligibility For Pregnant

Medi-Cal Handbookpage 35-7Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)35.1.6Unmarried Fathers - MN/MI Medi-CalNote:This section does NOT apply to Section 1931(b) Medi-Cal. [Refer to “PregnantWoman,” page 23-25 for information about unmarried fathers of unborns in theSection 1931(b) program.]MFBUAn unmarried father living in the home is not required to be in the MN/MI MFBUuntil the month following the month that his child turns age one, unless he isrequesting Medi-Cal for himself and/or any of his separate or mutual children. Theunmarried father must be added to the MFBU the first of the month after the infantturns one year old.Income/Property Increases in the income or property of an unmarried father DO NOT affect theinfant until the child reaches age one, regardless of whether the unmarried fatherwants 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 turnsage one.U-Parent LinkageIf an unmarried pregnant woman or the unmarried father in the home isunemployed, it is important that EWs explore and explain the benefits ofestablishing 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 unmarriedpregnant woman whenever possible.If.Then the EW shall.AFDC-MN linkage for the pregnant womanis dependent on the cooperation of theunmarried father in the home.Document in [Maintain Case Comments]whether or not he wishes to cooperate inestablishing linkage for the pregnant woman.Update # 16-03Revised: 02/03/16

page 35-8Medi-Cal HandbookContinued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)If.Then the EW shall.The unmarried father is willing to provideemployment information, have himcomplete an MC 210 S-WEstablish eligibility for the pregnant womanunder AFDC-MN (Aid Codes 34 or 37) ifU-Parent deprivation exists.The unmarried father does not cooperate inproviding information, and AFDC-MNlinkage for the pregnant woman cannot beestablished otherwise.Establish eligibility for the pregnant womanunder the MI program (Aid Codes 86 or 87).Information ProvidedAlthough an unmarried father is not required to be in the MN/MI MFBU until thenewborn reaches age one, occasionally he may provide all necessary informationand verifications. When this occurs: He may be included in the MFBU. If adding him adversely affects the mother or child (results in excess property ora 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 choosesto do so. However, it is not an error to include him if Sneede procedures arefollowed, because the end results will be the same. (NOTE: The unmarried father ofan unborn must always be included in the MFBU for Section 1931(b).35.1.7SneedeIn cases where there is an unmarried father in the home and the MFBU has a shareof cost or excess property, the following rules apply when determining eligibility forthe 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 childrenand there is a SOC or excess property, Sneede rules apply. [Refer to “CourtOrders: Sneede v Kizer,” page 70-1.] Include the newborn under age one in the Responsible Relativedetermination, even though the newborn will not actually receive an allocationfrom the unmarried father until the month after the child turns age one. There is to be NO ALLOCATION FROM THE UNMARRIED FATHER TO THEINFANT during Continued Eligibility.Revised: 02/03/16Update # 16-03

Medi-Cal Handbookpage 35-9Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC) 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, evaluatethem 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.35.1.8Medical Support EnforcementFor purposes of medical support enforcement, an absent parent still has a legalresponsibility for the health and welfare of his child(ren). A medical support referralmust be made at the end of the mother’s 60-day postpartum period if there is anabsent parent.35.1.9Three Month RetroactiveUse actual income to determine the share of cost for each retroactive monthrequested. Once an increase in income is reported subsequent to the month ofapplication, the increase is to be disregarded. Increases in income after the monthof application trigger Continued Eligibility, not the family's income in the retroactivemonths 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 requestsRetro Medi-Cal for August and September. She completes the application processon 11/15/11. Her net nonexempt income is as follows:(Retro)(Retro)(App. Mo.)(Current Mo.)8/119/1110/1111/11None 1,000 1,200 1,800Actual income is budgeted for August and September. In November, her income ismuch higher. Since she applied during the month of October, the income increasein November is disregarded under Continued Eligibility rules. Even though sheapplied after the baby was born, October is not a “Retro” month; therefore, CE rulesapply. Once her SOC for 10/11 is “certified”, she receives zero SOC postpartumservices for November and December. The newborn's SOC is based on October'sincome until the child turns age one, unless income decreases.Update # 16-03Revised: 02/03/16

page 35-10Medi-Cal HandbookContinued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)An infant can receive DE retroactively when one of the three months prior to theapplication month is the infant’s birth month and the mother, parent, legal guardianor responsible relative of the infant requests Medi-Cal coverage for that month. Ifthe infant’s mother had Medi-Cal eligibility in the birth month, then apply DE to theinfant beginning in that retroactive month.Example 1:A mother applies for Medi-Cal on July 6, 2011 for herself and her infant. Theinfant’s date of birth was June 16, 2011. The mother indicates on her applicationthat she has unpaid medical bills for May and June and requests Medi-Cal for Mayand June. The EW approves Medi-Cal for July 2011 and ongoing. In determiningher retroactive Medi-Cal eligibility, the EW determined that she was not eligible inMay but eligible for June. Because the infant’s month of birth is in the retro month ofJune and the mother was Medi-Cal eligible in June, the infant has DE beginning inJune.35.1.10Break In AidOnce 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 movesfrom County A and fails to notify their EW, so the case is discontinued 10/31. Thefamily reapplies in County B after the 30 day timeframe allowed by SB 87. This isconsidered a break in aid for purposes of determining Continuing Eligibility. CountyB determines eligibility and SOC based on November's income.35.1.11Intercounty Transfers (ICTs)If an ICT is received, the client is entitled to CE, per the requirements set forth inthis section, as no break in aid occurs.When initiating an ICT for a beneficiary who is entitled to CE, EWs must includeadequate documentation/explanation for the Receiving county.35.1.12Whereabouts UnknownIf the mother’s and infant’s whereabouts become unknown, the case may bediscontinued with a timely notice of action after following SB 87 procedures for lossof contact. However, if the family reestablishes contact, and the infant remained inCalifornia continuously since the discontinuance, the following applies:Revised: 02/03/16Update # 16-03

Medi-Cal Handbookpage 35-11Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC) The infant’s eligibility must be restored back to the date of discontinuance andthrough the current month. Even if the infant reached age one or ceased toreside with the mother at some point during the period of discontinuance, theinfant’s eligibility is uninterrupted because no timely NOA was given. If CE requirements were met in every month of the discontinuance period, theEW must determine whether the requirements are expected to be met in thefuture month. If so, CE continues. If the EW determines that the infant did notmeet the requirements in any of these prior months, the EW must determinewhether the infant has Medi-Cal eligibility on any other basis. If no other basis foreligibility exists, the infant can be discontinued with a timely notice of action.35.1.13Annual RedeterminationsThe following requirements apply when an MFBU includes a pregnant womanand/or a child under age one: Redeterminations must be completed annually as a condition of eligibility forpregnant women. The infant is given the same annual redetermination as the rest of the family andwill have his/her annual RD completed along with the family’s, even if thefamily’s annual redetermination date is before the infant’s first birthday. Deemed eligibility continues until age one regardless of any adverse actions thatmay apply to the rest of the family. Failure of the mother to complete the annual RD only affects the mother’seligibility and does not affect the infant’s deemed eligibility. Regular Medi-Cal requirements apply for the mother and other family members ifthe client fails to complete the annual RD or provide all necessary information orverifications to complete the RD.Important:For AFDC/MN-MI Medi-Cal, do not request verification of the income orresources 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 # 16-03Revised: 02/03/16

page 35-12Medi-Cal HandbookContinued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)35.1.14Increased Income, Pregnant Woman (MN/MI Programs)Use this chart to determine under which program a pregnant woman's eligibilitycontinues when there is an increase in family income or SOC:If the Prior MonthAid is.And IncomeIncreases.Then Continue Eligibility for the PregnantWoman under.No SOC, MN/MI orPA/Other PABut does not exceedMaintenance NeedMN/MI, no SOC. (Unaffected by Continued Eligibility)BetweenMaintenance Needand 200% of FPLIncome Disregard Program for pregnancy relatedservices. Increase her SOC for nonpregnancy care.Over 200%Income Disregard Program for pregnancy relatedservices. Increase her SOC for nonpregnancy care.Income DisregardProgram (betweenMaintenance Needand 200% of FPL)At or Below 200%Income Disregard Program for pregnancy relatedservices. Increase her SOC for nonpregnancy care.Over 200%Income Disregard Program for pregnancy relatedservices. Increase her SOC for nonpregnancy care.Property WaiverProvisionAt or Below 200%Property Waiver Provision for pregnancy relatedservices.Over 200%Property Waiver Provision for pregnancy relatedservices. (Use Income Disregard Program AidCode.)Still Over 200%Continue pregnant woman at prior month's SOC forboth her pregnancy and nonpregnancy services.SOC, MN/MI(Income over200%)Decreases in family income are still considered.Revised: 02/03/16Update # 16-03

Medi-Cal Handbookpage 35-13Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)35.1.15Increased Income, Infants (MN/MI Programs)Use this chart to determine under which program an infant's eligibility continuesthrough the month that the child turns age one, when there is an increase in familyincome or SOC:If the Prior MonthAid is.And IncomeIncreases.No SOC, MN/MI orPA/Other PABut does not exceedMaintenance NeedMN/MI, no SOC. (Unaffected by Continued Eligibility)BetweenMaintenance Needand 200% of FPLIncome Disregard Program. No SOC.Over 200%Income Disregard Program. No SOC.At or Below 200%Income Disregard Program. No SOC.Over 200%Income Disregard Program. No SOC.At or Below 200%Property Waiver Provision. No SOC.Over 200%Property Waiver Provision. No SOC.(Use Income Disregard Program Aid Code.)Still Over 200%Continue infant at prior month's SOC.Income DisregardProgram (betweenMaintenance Needand 200% FPL)Property WaiverProvisionSOC, MN/MI(Income over200%)Then Continue Eligibility for the Infant under.The SOC for other MFBU members is increased, except for a pregnant woman'spregnancy related services.Decreases in family income are still considered.35.1.16Increased Income,PA/Other PA Recipients/Section 1931(b)Pregnant women and infants who are discontinued from CalWORKs, Section1931(b), Transitional Medi-Cal (TMC), or Edwards are potentially eligible forContinued Eligibility.Update # 16-03Revised: 02/03/16

page 35-14Medi-Cal HandbookContinued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)Determine eligibility for no share of cost (SOC) Medi-Cal in the following sequence:StepAction1.When a pregnant woman and/or infant under age one is discontinued fromCalWORKs, first determine eligibility under the Section 1931(b) program.NOTE: Edwards Medi-Cal is appropriate if there is NOT enough information in thecase 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 TransitionalMedi-Cal (TMC).3.If ineligible for TMC, determine ongoing Medi-Cal eligibility under the MN/MIprograms.Disregard increases in family income for the pregnancy related services and for theinfant's SOC determination.If Income is:Then Establish Medi-Cal under:At or below Maintenance Need LevelMN/MI Program, No SOC, unaffected byContinued Eligibility.Above Maintenance Need Level(regardless of how high the income is)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 nonpregnancycare.NOTE: Other children in the MFBU maybe eligible for No SOC under FederalPoverty Level programs.35.1.17Determining MFBUs/SOCThe following examples describe situations when family income increases:Example 1A family of 4 includes Mom (pregnant), Dad, and their 4 year old child. Atapplication 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: 02/03/16Update # 16-03

Medi-Cal Handbookpage 35-15Continued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)Three months later, the family reports income over 200% of FPL. The increasedSOC is applied to all MI family members the first of the following month. Mom staysactive under the Income Disregard Program with the same Aid Code until the endof the 60 day postpartum period, without regard to any increases in income. Thenewborn will later be activated under the Income Disregard Program. Increases infamily income will not affect the newborn until age one, as long as other eligibilitycriteria are met.Example 2A 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 toher earnings. Section 1931(b) is discontinued and the first 6 months of TMC isapproved (April thru September).The family does not qualify for the second 6 months of TMC because their incomeis too high. The EW approves AFDC-MN with a SOC. Since the child is not yet oneyear 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 3An unmarried pregnant woman lives alone and has net nonexempt income of 1000 per month; therefore, she is eligible for the 200% Income Disregard Programwith no SOC for her pregnancy related services. During her pregnancy, her incomeincreases 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 untilthe 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 IncomeDisregard Program and her full scope Medi-Cal continues with a SOC. The newborn continues to be eligible under the Income Disregard Program, withno SOC, through the month the child attains age one, provided all other DEeligibility factors are met.Update # 16-03Revised: 02/03/16

page 35-16Medi-Cal HandbookContinued Eligibility for Pregnant Women, Infants, and Children (CE, DE, CEC)Example 4A family of 4 includes Mom (pregnant), Dad, and their 3 year old child. In OctoberDad is fully employed and net nonexempt income is over 200% of FPL, so theyhave 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 herpregnancy and non pregnancy related services. MEDS does not allow an individualto have two different SOC amounts with the same Aid Code simultaneously in thesame month.Change in MFBU SizeContinued Eligibility rules apply when changes in the size of the MFBU and/or inthe Maintenance Need Level cause an increase in the SOC.For example, a family member moves out of the house, but the household's incomeremains the same. The SOC increases due to the new, lower Maintenance NeedLevel. The SOC increase is NOT applied to the pregnant woman and/or infant.35.2 Deemed Eligibility for Infants35.2.1OverviewInfants born to women who are eligible for and receiving Medi-Cal on the date ofthe 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 cons

Feb 03, 2016 · 2000), mandates a new M edi-Cal provision for Continu ous 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