California Code of Regulations
Title 10 - Investment
Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program
Article 2 - Eligibility, Application, and Enrollment
Section 2699.6607 - Determination of Eligibility

Universal Citation: 10 CA Code of Regs 2699.6607

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Except as specified in Section 2699.6605, the program shall complete the application review process within ten (10) calendar days of receipt of the complete application or Add a Person Form unless the program is waiting for necessary information pursuant to Subsection 2699.6606(b)(1) and (2) or is requesting information pursuant to Subsection 2699.6600(c)(1)(BB)(1). For those applications, the program shall complete the application review process within twenty (20) calendar days of receipt of the original application or Add a Person Form.

(1) The program shall determine eligibility for each person age 18 or under based upon the criteria specified in Insurance Code Sections 12693.70, 12693.73 and 12693.76 and this section.

(2) The program shall determine eligibility for each person age 19 and over based on the criteria specified in this section. Notwithstanding any other provision of this Chapter, the first date on which any person age 19 or over shall be eligible for the program is the parental coverage start date. In addition to the criteria applicable to all potential subscribers, to be a child-linked adult eligible to participate in the program, a person age 19 or over must meet all the following requirements:
(A) Is not eligible for no-cost full-scope, or pregnancy-related, Medi-Cal or Medicare Part A and B at the time of enrollment in the program.

(B) 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.

(C) Is in a family with an annual or monthly household income after income deductions of up to and including 200 percent of the federal poverty level. Any income deduction that is applicable to a child under Medi-Cal shall be applied in determining the annual or monthly household income.

(D) If a person age 19 or over for whom enrollment in the program is requested has an annual or monthly household income after income deductions of 100 percent of the federal poverty level or below, a letter or Notice of Action from the County Welfare Office issued within the last two (2) months must state that the individual is not eligible for no-cost Medi-Cal for a reason other than:
1. failure to provide information requested by Medi-Cal or

2. termination from no-cost Medi-Cal at his or her own request.

(E) Notwithstanding 2699.6607(a)(2)(D), legal guardians applying to the program for coverage with an annual household income after income deductions of 100 percent of the federal poverty level or below do not need to provide a Notice of Action from the County Welfare Office.

(F) Meets the definition of child-linked adult as defined in Section 2699.6500.

(G) Has a qualifying event as defined in Section 2699.6500 or applies pursuant to Section 2699.6631 for the first year following the parental coverage start date.

(3) If the program does not have the documentation required by Subsection 2699.6600(c)(1)(T), the person shall be temporarily deemed to meet citizenship or immigration criteria until such documentation is submitted or until the time for submitting documentation established in Subsection 2699.6600(c)(1)(T) has expired, whichever is sooner.

(b) The program shall disregard any stepparent's income in determining income eligibility for a stepchild.

(c) The program shall disregard any child's income in determining income eligibility for any other person.

(d) If any persons for whom application is being made currently have employer sponsored health coverage, these persons shall be determined ineligible. If employer sponsored health coverage was terminated for any persons for whom application is being made within the last three (3) months, these persons shall be determined ineligible, unless the reason for the termination is one of the following:

(1) The person through whom the employer sponsored coverage had been available either
(A) lost employment or experienced a change in employment status,

(B) changed address to a zip code that is not covered by the employer-sponsored coverage,

(C) lost health benefits because the person's employer discontinued health benefits to all employees or dependents, or ceased to provide coverage or contributions for one or more categories of employees or dependents, or

(D) lost coverage because of death of the individual through whom the children or child-linked adults were covered, or a legal separation or divorce from the individual through whom the children or child-linked adults were covered.

(2) The person for whom application is being made was covered under a COBRA policy, and the COBRA coverage period has ended.

(3) The person for whom application is being made had coverage provided under an exemption authorized under subdivision (i) of Section 1367 of the Health and Safety Code.

(e)

(1) Subject to paragraph (2) below, an alien shall only be eligible for the program if the alien is a qualified alien.

(2)
(A) In any fiscal year that the annual Budget Act provides the necessary funding, a person who is a qualified alien shall not be determined ineligible solely on the basis on his or her date of entry into the United States. If the annual Budget Act does not provide the necessary funding, and except as provided in subparagraph (B) below, a person who is a qualified alien and who entered or enters the United States on or after August 22, 1996, is not eligible for a period of five years beginning on the date of the alien's entry into the United States with a status within the meaning of the term qualified alien.

(B) The limitation under paragraph (2)(A) above shall not apply to the following aliens:
1. An alien who is admitted to the United States as refugee under Section 207 of the Immigration and Naturalization Act (INA).

2. An alien who is granted asylum under Section 208 of the INA.

3. An alien whose deportation is being withheld under Section 243(h) of the INA (8 U.S.C. Section 1230(h)) (as in effect immediately before the effective date (April 1, 1997) of Section 307 of Division (C) of Public Law 104-208) or Section 241(b)(3) of the INA (8 U.S.C. Section 1251(b)(3) (as amended by Section 305(a) of Division C of Public Law 104-208).

4. An alien who is a Cuban or Haitian entrant as defined in Section 501(e) of the Refugee Education Assistance Act of 1980.

5. An alien admitted to the United States as an Amerasian immigrant as described in Section 1612(a)(2)(A) (v.) of Title 8 of the United States Code.

6. An alien who is lawfully residing in any state and is any of the following:
a. A veteran (as defined in Section 101, 1101, or 1301, or as described in Section 107 of Title 38 of the United States Code) with a discharge characterized as an honorable discharge and not on account of alienage and who fulfills the minimum active-duty service requirement of Section 5303 A(d) of Title 38 of the United States Code.

b. On active duty (other than active duty for training) in the Armed Forces of the United States.

c. The spouse or unmarried dependent child of an individual described in subparagraph a. or b. or the unremarried surviving spouse of an individual described in subparagraph a. or b. who is deceased if the marriage fulfills the requirements of Section 1304 of Title 38 of the United States Code.

(3) The program shall verify the status of any person for whom application is being made to confirm that the person is a citizen, a non-citizen national of the United States, or a qualified alien.

(f) If the applicant does not select a health, dental and/or vision plan and the person being applied for is eligible for the program, the program shall assign the health, dental and/or vision plan as follows:

(1) Automatic assignment of the health plan to the community provider plan. If the community provider plan is not available, alternate assignment to an available health plan; and/or

(2) Alternate assignment of the dental and/or vision plan.

(3) Assignment of the dental plan shall be made pursuant to Section 2699.6600(c)(1)(BB)1. and 2699.6623.

(g) If application was made pursuant to Section 2699.6602(d), eligibility is contingent upon receipt by the program of documentation of the child's birth within thirty (30) days of the birth.

(h) Applicants will be notified in writing of the eligibility determination for each person applied for. If a person is determined ineligible the notice shall include the reason for the determination of ineligibility and an explanation of the appeal process. The family contribution for any persons determined ineligible which was included with the application shall be refunded. If appropriate, and if permission is given by the applicant, the application shall be forwarded to the Medi-Cal program for eligibility determination.

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment of subsection (a) filed 12-14-98 as an emergency; operative 12-14-98 (Register 98, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-13-99 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 12-14-98 order transmitted to OAL 3-25-99 and filed 5-6-99 (Register 99, No. 19).
5. Amendment of subsections (a) and (e) filed 5-26-99 as an emergency; operative 5-26-99 (Register 99, No. 22). A Certificate of Compliance must be transmitted to OAL by 9-23-99 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 5-26-99 order, including further amendment of subsections (a) and (c), transmitted to OAL 9-17-99 and filed 10-28-99 (Register 99, No. 44).
7. Amendment of subsections (a) and (d)(1), new subsection (e) and subsection relettering filed 1-10-2000 as an emergency; operative 1-10-2000 (Register 2000, No. 2). A Certificate of Compliance must be transmitted to OAL by 5-9-2000 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 1-10-2000 order, including amendment of subsections (d)(2)(B)4. and (f), transmitted to OAL 5-5-2000 and filed 6-16-2000 (Register 2000, No. 24).
9. Amendment of subsection (f) filed 9-5-2000; operative 9-5-2000 pursuant to Government Code 11343.4(d) (Register 2000, No. 36).
10. Amendment of section and NOTE filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 4-29-2002 order, including new subsection (a)(2)E), subsection relettering and amendment of newly designated subsection (a)(2)(G) and subsection (d)(2), transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
12. Amendment of subsections (a)(1)-(2) and (e)(2)(B)5. filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).
14. Amendment of subsections (a) and (a)(3) filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
16. Editorial correction of subsection (g) (Register 2007, No. 30).
17. Amendment of subsections (a) and (f) filed 7-31-2007 as an emergency; operative 7-31-2007 (Register 2007, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-28-2008 or emergency language will be repealed by operation of law on the following day.
18. Amendment of subsection (g) filed 11-30-2007 as an emergency; operative 11-30-2007 (Register 2007, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-28-2008 or emergency language will be repealed by operation of law on the following day.
19. Certificate of Compliance as to 7-31-2007 order transmitted to OAL 1-28-2008 and filed 3-12-2008 (Register 2008, No. 11).
20. Certificate of Compliance as to 11-30-2007 order transmitted to OAL 5-28-2008 and filed 7-7-2008 (Register 2008, No. 28).
21. New subsection (f)(3) and amendment of NOTE filed 10-29-2009; operative 11-1-2009 pursuant to Government Code section 11346.1(d) (Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL by 4-30-2010 or emergency action will be repealed by operation of law on the following day. This regulatory action is deemed to meet the emergency standard and is exempt from OAL review pursuant to Insurance Code section 12693.22.
22. Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010 and filed 6-9-2010 (Register 2010, No. 24).

Note: Authority cited: Sections 12693.21, 12693.22 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.22, 12693.70, 12693.71, 12693.73 and 12693.755, Insurance Code.

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