(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 213 A 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.
