Eligibility for Individuals and Families
Participant Guide
Version 3.0
Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
TABLE CONTENTS
1 Course Objectives ................................................................................................... 1
2 Overview of the Application and Enrollment Process .......................................... 1
HOW TO APPLY FOR COVERAGE................................................................................................... 1
APPLICATION SECTIONS AND QUESTIONS ..................................................................................... 2
APPLICATION PROCESSING TIMES ................................................................................................ 4
RESOLVING INCONSISTENCIES ...................................................................................................... 4
ENROLLMENT PERIODS ................................................................................................................ 6
SPECIAL ENROLLMENT AND QUALIFYING EVENTS ......................................................................... 7
3 Determining Eligibility Based on Household Income and Size.......................... 11
HOUSEHOLD INCOME AND FEDERAL POVERTY LEVEL ...................................................................11
ELIGIBILITY AND MODIFIED ADJUSTED GROSS INCOME .................................................................11
CALCULATING MAGI ..................................................................................................................12
VERIFYING HOUSEHOLD SIZE AND INCOME...................................................................................13
PROJECTING SELF-EMPLOYMENT INCOME FOR MAGI ...................................................................13
MIXED PROGRAM FAMILIES .........................................................................................................13
4 Covered California Eligibility Requirements ....................................................... 16
WHO CAN APPLY FOR COVERAGE?.............................................................................................16
UNDERSTANDING LAWFUL PRESENCE, IMMIGRATION STATUS, DOCUMENTATION AND ELIGIBILITY ..16
VERIFYING RESIDENCY, INCARCERATION, CITIZENSHIP AND IMMIGRATION STATUS FOR COVERED
CALIFORNIA HEALTH PLANS .......................................................................................................20
5 Medi-Cal Health Coverage and Eligibility ............................................................ 20
MEDI-CAL ELIGIBILITY OVERVIEW ...............................................................................................20
EXPANDED MEDI-CAL GROUP .....................................................................................................21
OTHER MEDI-CAL GROUP ...........................................................................................................21
FORMER FOSTER CARE CHILDREN’S PROGRAM ...........................................................................22
CITIZENSHIP AND IMMIGRATION STATUS FOR MEDI-CAL ELIGIBILITY ..............................................22
CALIFORNIA MEDI-CAL RESIDENCE REQUIREMENTS ....................................................................24
NO FIVE-YEAR WAITING PERIOD IN CALIFORNIA FOR LAWFULLY PRESENT INDIVIDUALS ................24
MEDI-CAL ELIGIBILITY DETERMINATION FOR HOUSEHOLD INCOME AND SIZE .................................24
ELIGIBILITY DETERMINATION PROCESS ........................................................................................25
ENROLLMENT PERIOD AND APPLICATION PROCESSING TIMES ......................................................26
PRESUMPTIVE ELIGIBILITY PROGRAMS ........................................................................................26
MEDI-CAL ESTATE RECOVERY PROGRAM ....................................................................................27
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM...............................................................28
CONCERNS OR COMPLAINTS .......................................................................................................29
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
6 Eligibility and Enrollment for American Indians and Alaska Natives ................ 29
ELIGIBILITY FOR THE ELIMINATION OF COST-SHARING EXPENSES .................................................30
EXEMPTION FROM INDIVIDUAL MANDATE PENALTIES ....................................................................31
ENROLLMENT PERIODS ...............................................................................................................31
VERIFICATION OF STATUS ...........................................................................................................31
7 Processes for Referrals, Appeals and Complaints ............................................. 31
REFERRALS TO NON-COVERED CALIFORNIA HEALTH PROGRAMS .................................................31
CONSUMER APPEALS PROCESS ..................................................................................................32
SUPPORT FOR CONSUMERS WITH CONCERNS OR COMPLAINTS .....................................................32
8 Endnotes ................................................................................................................ 34
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
1 COURSE OBJECTIVES
 Explain how and when the consumer can apply for coverage
 Explain enrollment periods and qualifying life events
 Describe the eligibility requirements for Covered California health plans and Medi-Cal
 Understand how to determine tax household income and size
 Describe eligibility, verification and the enrollment process for American Indians and
Alaska Natives
 Describe the appeals process for consumers
2 OVERVIEW OF THE APPLICATION AND ENROLLMENT PROCESS
HOW TO APPLY FOR COVERAGE
The first step in obtaining coverage begins with the consumer completing the Covered California
enrollment application. Consumers can apply in the way that works best for them, including:

Online at: www.CoveredCA.com

In-person with an individual certified by Covered California to perform enrollment
assistance

In-person with an eligibility worker at a county social service office

By contacting the Covered California Service Center at (800) 300-1506

By US Postal mail or by fax (this is not the preferred application method as it may result
in a delayed eligibility determination)
The Covered California enrollment application asks questions that are necessary for
determining eligibility, including:

Number of household members: members who need health insurance, and their place
of residence

Income of tax household members: includes salaries, wages, and unearned income

Citizenship/immigration status of those applying for coverage

Social Security Numbers (SSN), or Individual Taxpayer Identification Numbers
(ITIN), which are used to verify income and immigration/residence status. SSNs will not
be necessary for individuals who do not require health insurance, but are helpful in
verifying information for those applying for coverage. For example, a mother who is not
seeking coverage for herself and is applying for one of her children only needs to
provide the child’s SSN, if available

Rights and Responsibilities page: must be signed by the consumer (or their
authorized representative). This page cannot be signed by the consumer’s Certified
Enrollment Counselor or other certified in-person assister. By signing this page, the
consumer acknowledges that they:
o
o
o
Have provided true and accurate information
Understand their rights as consumer
Agree to other responsibilities, such as annual redetermination and reporting income
changes
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
Consumers will be determined eligible for one of three paths to health coverage through
Covered California:
1. A Covered California health plan at full price (without financial assistance)
2. A Covered California health plan with financial assistance
3. Referred to Medi-Cal
APPLICATION SECTIONS AND QUESTIONS
Understanding the application sections and the information required are key to submitting a
complete and successful application. The application is a dynamic process and may create
additional fields depending on the information submitted by the consumer.
Important – Disclosure of Immigration Status
All information provided about immigration status for determining eligibility for health
coverage through Covered California will be kept secure and private. Under NO
circumstances will this information be used by an immigration agency for the purpose
of enforcement.
The following is an overview of the sections of the application:
Application Section
Getting Started
Primary Contact
Information
Questions (General Summary)


Whether or not the consumer is applying for financial assistance

Whether the consumer is applying during the special-enrollment
period



General questions regarding household size
Whether the consumer is getting assistance in filling out the
application (i.e. from a Certified Enrollment Counselor)
How the consumer learned about Covered California
Consent to the information verification process performed by
Covered California
This information includes:





Name


Method of communication

Information about individuals living in the home and whether
they are applying for coverage (tax dependents are considered
household members whether or not they live in the home)

Name
Telephone number
Home mailing address
Email address
Identity Verification Process (Remote Identity Proofing)
Preferences for:
Additional Household
Members
Written and spoken language
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Application Section
Applicant and Household
Member Demographic
Data
Applicant’s Additional
Household Member(s)
Tax Information
Version 3.0
Questions (General Summary)



Date of birth



Social Security Number or Alien Number


Marital status

Member of a federally recognized American Indian/Alaska
Native


Full-time student

Medical expenses in the last three months (relevant if consumer
requests retroactive Medi-Cal coverage)


Pending medical bills within the last three months
Gender
US citizen, national or lawfully present status if applying for
coverage through Covered California
Relationship of household members to each other
Contact information if different from that of the primary contact
Pregnancy status and, if pregnant, due date and number of
children expected
Blind or disabled, or both (for non-MAGI Medi-Cal eligibility
determination)
In foster care at the age of 18 (for Medi-Cal eligibility
consideration)
Tax filing status:




Number of dependents claimed

Whether they have employer-sponsored health insurance
coverage that meets the minimum standard value and
affordability tests

Long-term care needs (for non-MAGI Medi-Cal eligibility
determination)

Medicare coverage status
Applying Family
Members’ Request for
Referral to Non-Health
Care Service Programs

CalWORKS Program

CalFresh Program
Optional Information



Ethnicity


Income type
Applying Family
Members’ Health Care
Information
Income Information
Head of household status
Agrees to file a tax return(s) for the current benefit year
Whether or not the consumer filed taxes in the previous benefit
year
Race
Languages spoken / written
Income source
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Application Section
Questions (General Summary)


Income Summary
Signature Page
Version 3.0
Income amount
Frequency of payment
Review of consumer’s current and projected annual income (for the
current benefit year)


Consumer’s rights and responsibilities
Consumer’s signature
APPLICATION PROCESSING TIMES
Covered California’s goal is to provide consumers with health insurance as quickly and easily as
possible. Application processing times vary according to:

The manner in which the application is submitted

Whether or not the application is complete and has consistent information

Whether the application requires further verification
The table below provides additional information on the processing time, based on application
submission method:
Application Submission Method
 Online
 Certified In-Person Counselor or
Agent
 By telephone
Paper applications that are received by
conventional mail or fax
Time Frame
Processing will take more time if additional
information is required or if inconsistent
information is provided
Processed in real time. This applies to
applications that do not require resolution of any
inconsistent information
Within 10 calendar days
Missing or inconsistent information may cause a
processing delay
Applying the Reasonably Compatible Standard to Consumer Information
Covered California applies a reasonably compatible standard to any differences or
discrepancies between the application information and the verification data sources. In other
words, slight differences will not impact a consumer’s eligibility. However, if the consumer’s
attestation is not reasonably compatible with available information or data, then Covered
California will follow a process to resolve inconsistencies.
RESOLVING INCONSISTENCIES
Consumers have 90 days to resolve an inconsistency between eligibility information they
provided on the application versus what was determined by the federal data sources.
NOTE: If an application requires resolution of an inconsistency based on income, the consumer
may be conditionally eligible for a Covered California health plan and use any premium
assistance and cost-sharing reductions if their attested information qualifies them. It is
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
important to know that if it turns out they are not eligible they must pay back any
premium assistance amount received, up to a certain dollar amount.
A process is in place to resolve inconsistencies identified when information from the consumer
is not reasonably compatible with Covered California data sources.
The steps are as follows:
Step 1:
Covered California first tries to address the cause of the inconsistency between
the data sources and the consumer’s attestation by requesting a reasonable
explanation from the consumer. If the consumer provides a reasonable
explanation for the discrepancy, eligibility is determined based on the information
the consumer provides.
Example
A consumer may have recently lost their job and currently has no income. This may be
considered a reasonable explanation for why the current data sources indicate the
individual’s earnings are above Medi-Cal eligibility levels.
If the consumer is unable to provide a reasonable explanation, Step 2 is followed.
Step 2:
Covered California notifies the consumer about the inconsistency and requests
acceptable verification documents.
Documentation must be submitted within 90 days of submitting the application. Consumers
can upload the document(s) on their online Covered California account (preferred) or send a
copy via fax at 888.329.3700 or mail it to:
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
Examples
If an individual attests to their income and Covered California was unable to verify the
attestation against current data sources, the individual may be required to provide their
most recent pay stubs;
OR
If an individual attests to being a lawful permanent resident, but Covered California is
unable to verify this status with the Department of Homeland Security, the consumer may
have to provide a copy of their Green Card (or other lawfully present documentation).
During the 90-day resolution period, Covered California proceeds with all other elements of
eligibility determination and may provide temporary coverage with financial assistance, which
includes making sure that any advance payments for premium assistance and cost-sharing
reductions are applied. Consumers are required to attest that they understand that any
payments made on their behalf must be reconciled when they file their tax return for the
benefit year.
Step 3:
If, after Step 2, Covered California still is unable to verify the consumer’s
information, eligibility for financial assistance will be decided based on the
information from the databases used to verify the information reported by the
consumer. In the case of Medi-Cal eligibility, certain information that cannot be
verified will halt the eligibility process, and the consumer’s county social services
office will follow up directly with the individual.
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
NOTE: Covered California is required to make a determination between 10 and 30 days after
the date it sent the notice to the consumer that there was an inconsistency.
Requesting an Extension
Consumers who need more time to address inconsistencies can request an extension by using
the following procedure:
Step 1:
The consumer should contact the Covered California Service Center at (800)
300-1506 to explain why they need an extension.
Step 2:
Covered California will review the request and send a decision to the consumer.
If Covered California approves the extension, they will follow up with the
consumer by phone or written notice within 30 days from the date of extension
approval.
Example
An extension may be granted if a consumer demonstrates that they are making every
effort to obtain documentation to resolve an inconsistency. For instance, the consumer
provides Covered California with a photocopy of a letter or email message sent to an
agency requesting the necessary documentation.
Step 3:
The consumer has 30 days from the date of the Covered California notice of
approval for an extension to respond. If the consumer responds to the notice
explains why they still cannot provide the documents, Covered California will
determine if they continue to qualify for the extension and will send written
notification about the decision to the consumer.
Case-by-Case Exceptions
On a case-by-case basis, Covered California may accept a consumer’s explanation of the
information which cannot be verified and the circumstances preventing them from obtaining
documentation if:

The documentation required to resolve the inconsistency does not exist or is not
reasonably available

The inconsistency is not related to citizenship or immigration status

Covered California has no other way to resolve the inconsistency for the consumer
As a last resort, the consumer can sign an attestation statement under penalty of perjury for
the information in question.
ENROLLMENT PERIODS
Open-Enrollment Period
Consumers who are eligible for a Covered California health plan, with or without financial
assistance, can apply for coverage during the annual open-enrollment period. Note: There are
no enrollment periods for Medi-Cal coverage. Consumers eligible for Medi-Cal may enroll at any
time throughout the year. The initial open enrollment for period was October 1, 2013 through
March 31, 2014.
2015 Open Enrollment starts November 15, 2014 and runs through February 15, 2015.
For subsequent years, the open-enrollment period will run from Oct. 15 to Dec. 7.
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
Key enrollment, premium payment and coverage effective dates Covered California health
plans:
Enrollment Date
Premium Due Date
Coverage Effective Date
Between the 1st and 15th of
the month
Four business days before
the end of each month
The first day of the following month
Example: Coverage for a consumer
who enrolls and pays the premium
on March 10, 2014, will be effective
April 1, 2014.
Between the 16th and last day
of the month
Four business days before
the end of the following
month
The first day of the second following
month
Example: Coverage for a consumer
who enrolls and pays the premium
on March 17 will be effective May 1.
*Note: during open-enrollment 2015, coverage for consumers who enroll prior to December 15, 2014
will not be effective until January 1, 2015.
SPECIAL ENROLLMENT AND QUALIFYING EVENTS
Special enrollment is a time outside of the open-enrollment period during which consumers, with
certain circumstances known as qualifying events, can sign up for health care coverage.
Consumers can begin the special-enrollment process by going to CoveredCA.com or by
contacting the Covered California Service Center at 800-300-1506 or a certified in-person
counselor or agent.
Qualifying Events
For Covered California’s special-enrollment qualifying events should be reported within 60 days
of the date of the event. If consumers do not meet one of these qualifying events, they must wait
until the next year to enroll in coverage. When consumers apply for coverage, they will need to
select a qualifying life event from a drop-down menu and will be asked the date of the event.
The chart below will help you answer those questions.
QUALIFYING LIFE EVENT
DESCRIPTION
DATE TO ENTER ON
COVEREDCA.COM
COVERAGE EFFECTIVE DATE
LOSS OF HEALTH INSURANCE
 Loss of Medi-Cal coverage.
 Loss of employer-sponsored
coverage.
Enter the date of the loss of
coverage
 COBRA coverage is
exhausted. (Failure to pay
COBRA premium is not
considered loss of coverage.)
Page 7
The first day of the month
following the plan selection.
(Regardless of when the event
and the plan selection happened
throughout the month). For
retroactive coverage, contact
the Covered California Service
Center (800) 300-1506
Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
QUALIFYING LIFE EVENT
DESCRIPTION
DATE TO ENTER ON
COVEREDCA.COM
Version 3.0
COVERAGE EFFECTIVE DATE
 No longer eligible for student
health coverage.
 Consumer turns 26 years old
and are no longer eligible for
a family plan.
 Consumer turns 19 years old
and are no longer eligible for
a child-only plan.
PERMANENTLY MOVED TO/WITHIN CALIFORNIA
 Consumer moves to
California from out of state.
Enter the date of the permanent
move
 Consumer moves within
California and gain access to
at least one new Covered
California health plan.
If a plan is selected by the 15th,
coverage starts on the following
1st of the following month. If a
plan is selected after the 15th,
coverage starts on the 1st of the
second following month
HAD A BABY OR ADOPTED A CHILD
 A child is born, adopted or
received into foster care.
Enter the date of birth, adoption
or foster placement
 The consumer’s child is
placed for adoption or foster
care.
Day of Event (retroactive
coverage effective date). For
retroactive coverage contact the
Covered California Service
Center (800) 300-1506
GOT MARRIED OR ENTERED INTO A DOMESTIC PARTNERSHIP
 Two consumers, get married
or enter into a domestic
partnership. Both can apply.
Enter the date on the marriage
or domestic partnership license
 A consumer who has no
coverage marries or enters a
domestic partnership with a
consumer who has a Covered
California health plan. Both
can apply or renew their
coverage.
The first day of the month
following the plan selection.
(Regardless of when the event
and the plan selection happened
throughout the month). For
retroactive coverage contact the
Consumer Service Center (800)
300-1506
RETURNED FROM ACTIVE DUTY MILITARY SERVICE
Loss of coverage after leaving
active duty, reserve duty, or the
California National Guard.
Enter the date the consumer
returned from active duty.
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If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
QUALIFYING LIFE EVENT
DESCRIPTION
Version 3.0
DATE TO ENTER ON
COVEREDCA.COM
COVERAGE EFFECTIVE DATE
starts on the 1st of the second
following month.
RELEASED FROM INCARCERATION
Consumer is released from jail
or prison.
Enter the date you apply for
Covered California.
If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
starts on the 1st of the second
following month.
GAINED CITIZENSHIP/LAWFUL PRESENCE
Consumer becomes a citizen,
national, or permanent legal
resident.
Enter the date on the
immigration document.
If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
starts on the 1st of the second
following month.
AMERICAN INDIAN/ALASKAN NATIVE
Consumer is a member of a
federally recognized American
Indian tribe. Consumer may
apply at any time.
Enter the date you apply for
Covered California.
If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
starts on the 1st of the second
following month.
OTHER QUALIFYING LIFE EVENT

Consumer enrolled in a
Covered California health
plan and become newly
eligible or ineligible for tax
credits or cost-sharing
reductions.

Misconduct or
misinformation occurred
during the enrollment

Misrepresentation or
erroneous enrollment

Exceptional circumstances
occurred on or around plan
selection deadlines,
Enter the date you apply for
Covered California.
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If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
starts on the 1st of the second
following month. Covered
California may grant earlier
effective date based on the
specific circumstances of each
case.
Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
QUALIFYING LIFE EVENT
DESCRIPTION
DATE TO ENTER ON
COVEREDCA.COM
Version 3.0
COVERAGE EFFECTIVE DATE
including natural disasters
and medical emergencies.

Consumer received a
certificate of exemption for
hardship from Health and
Human Services for a
month or months during the
coverage year but lost
eligibility for the hardship
exemption outside of an
open-enrollment period.

Consumer started or ended
membership of
AmeriCorps/VISTA/
National Civilian Community
Corps outside of an openenrollment period

Consumer has a
grandfathered health
insurance plan

Consumer’s provider left the
health plan network while
receiving care for a serious
condition
NONE OF THE ABOVE
If none of these qualifying life
events are applicable, the
consumer should still apply for
coverage using "None of the
above," because they may be
eligible for Medi-Cal or the MediCal Access program for
pregnant women based on
income. Regardless of which life
event is selected, the
consumer’s application will still
be reviewed for eligibility in
Medi-Cal or the Medi-Cal Access
Program.
Enter the date you apply for
Covered California.
If a plan is selected by the 15th,
coverage starts on the 1st of the
following month. If a plan is
selected after the 15th, coverage
starts on the 1st of the second
following month.
The table below describes the health coverage effective date based on the date of the qualifying
event:
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Version 3.0
Date of Qualifying Event
Coverage Effective Date
Event occurring on the 1st through the 15th of
the month
First day of the following month
Event occurring on the 16th through the last
day of the month
First day of the second following month
Birth, adoption, or placement for adoption
Date of birth, adoption, or placement for adoption.
Note: any financial assistance will be effective the
first day of the following month of birth.
Marriage/Domestic Partnership
First day of the following month following plan
selection
3 DETERMINING ELIGIBILITY BASED ON HOUSEHOLD INCOME AND
SIZE
HOUSEHOLD INCOME AND FEDERAL POVERTY LEVEL
To determine eligibility options for consumers, the tax household income is compared with the
federal poverty level (FPL) guidelines for the household size. FPL is based on the minimum
amount of gross income (before taxes) that a household needs for food, clothing, transportation,
shelter, and other necessities. The US Department of Health and Human Services (HHS)
determines the FPL each year, which varies by family size and is adjusted for inflation. Medi-Cal
implements the new FPL guidelines on April first. Covered California, however, continues to use
the previous year’s FPL guidelines until the next open-enrollment period. During special
enrollment, the CoveredCA.com application factors in both the old and new FPL guidelines for
applications submitted prior to the start of the next open-enrollment period. For example, during
special enrollment in 2014, Covered California used the 2013 FPL thresholds and Medi-Cal
used the 2014 FPL thresholds. Covered California will use the 2014 FPLs for open enrollment,
which begins November 15, 2014 for coverage that starts January 1, 2015.
ELIGIBILITY AND MODIFIED ADJUSTED GROSS INCOME
A tax household’s modified adjusted gross income (MAGI) is used to determine eligibility for
subsidized health insurance through Covered California and for income-based Medi-Cal.
For most consumers, their adjusted gross income (AGI) is the same amount as their MAGI.
Consumers can find their AGI on the following federal tax return lines:
 Line 4, Form 1040EZ

Line 21, Form 1040A

Line 37, Form 1040
IMPORTANT TO NOTE: Taxpayers who receive non-taxable Social Security benefits, earn
income living abroad or earn non-exempt interest should add that income to their AGI to
calculate their MAGI. It is important to remind a consumer that if they claim a spouse or children
as dependents, their income counts towards the tax household income. In order to receive
financial assistance through Covered California, spouses are required to file their income tax
return jointly.
To perform MAGI calculations, Covered California requires consumers to provide the following:

An attestation to their current or projected income for the current benefit year.
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families

Version 3.0
If the consumer’s income varies from month to month, income should be based on a
monthly average of expected earnings for the current benefit year (projected average
annual income). To make this income estimate, consumers need to take the
following factors into consideration:
o
Their income pattern over the last year
o
The actual income they received in the last month
o
The ability to provide a statement of anticipated income, which can be presented
as a self-affidavit letter of income
If a consumer’s attested income is not reasonably consistent with available federal data, or if
income information is not available, the consumer has 90 days to provide Covered California
with documentation to resolve the inconsistency (i.e., by presenting current paystubs or the
previous year’s tax return).
CALCULATING MAGI
It is important to understand all sources of income that will be counted in MAGI as certain types
of income may be deducted or not included when calculating MAGI. The following table
describes sources of income as they relate to MAGI.
What is included in MAGI?
Wages, salaries, selfemployment income, tips,
and commissions
Taxable interest and
ordinary dividends
Taxable amount of a
pension, annuity, or IRA
distribution
Social Security benefits
Business income
Farm income
Capital gains and other
gains (or losses)
What is not included in
What is deducted from MAGI?
MAGI?
Certain allowable selfemployment expenses
Student loan interest
deduction
Educator expenses
IRA deduction
Moving expenses
Penalty on early withdrawal
of savings
Foster Care payments
Veterans’ disability
payments
Workers’ compensation
payments
Child support received
Supplemental Security
Income (SSI)
Also not included in MAGI
because these items are
already subtracted from W-2
wages and salaries are pretax contributions for:
Health savings account
deduction
 Child care
Unemployment
compensation
Alimony paid
Alimony received
Certain business expenses
of reservists, performing
 Employer-sponsored
health insurance
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 Commuting
Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
What is included in MAGI?
Income from rental real
estate, royalties, and
partnerships
Version 3.0
What is not included in
What is deducted from MAGI?
MAGI?
artists, and fee-basis
government officials
 Flexible spending
accounts
 Retirement plans such as
a 401(k) or 403(b)
Taxable refunds, credits, or
offsets of state and local
income taxes
Other taxable income
VERIFYING HOUSEHOLD SIZE AND INCOME
Covered California verifies household size and MAGI income using both tax return and state
data sources.
To verify the consumer’s attestation of income, Covered California obtains IRS tax return data
from the Secretary of the Treasury via the federal hub. When verifying a consumer’s attestation
of income for determining Medi-Cal eligibility, Covered California uses a combination of both
IRS data and current data sources. If IRS data is not available, or the consumer’s attestation is
not reasonably compatible with the IRS data, Covered California will rely on current data
sources.
PROJECTING SELF-EMPLOYMENT INCOME FOR MAGI
If an individual has worked less than a year, or not long enough to file a tax return in the
previous year, a projection of annual self-employment income can be made by:
1. Adding together gross self-employment income and any profit made from selling
business property or equipment during the time the business has been in operation
within the last year.
2. Subtracting business expenses allowed by the IRS.
One way to project self-employment income for the current benefit year is by using the income
and deductions claimed on the previous year’s taxes (Form 1040, Line 12 of Schedule C), if an
individual worked long enough to file a federal tax return for the previous year, and it is
representative of their current income.
MIXED PROGRAM FAMILIES
Members of the same family or household may be eligible for different types of health coverage.
Families in this situation are referred to as mixed program families. For example, a family’s
application could show that one parent who has affordable coverage through their job qualifies
to purchase a Covered California health plan with no financial assistance, while the other parent
may qualify for financial assistance through a Covered California health plan, while the children
could qualify for Medi-Cal.
The following table shows the available health coverage options available through Covered
California and the corresponding household size and income guidelines for 2015:
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Course Name: Eligibility for Individuals and Families
Version 3.0
Program Eligibility by Federal Poverty Level
Eligible for Premium Assistance (PA)
Household
Size
Premium
Assistance
(PA) Eligible
under
5-year bar
Eligible for Medi-Cal (MAGI)
Enhanced Silver Plan
Medi-Cal Kids Eligible (no PA)
Expanded
Medi-Cal (up
formerly Healthy Families
to 138%)
(up to 266%)
The Medi-Cal Access
Program* (213%-322%)
< 100%
100%
133%
138%
150%
200%
250%
300%
400%
1
$0- $11,669
$11,670
$15,521
$16,105
$17,505
$23,340
$29,175
$35,010
$46,680
2
$0 - $15,729
$15,730
$20,921
$21,707
$23,595
$31,460
$39,325
$47,190
$62,920
3
$0 - $19,789
$19,790
$26,321
$27,310
$29,685
$39,580
$49,475
$59,370
$79,160
4
$0 - $23,849
$23,850
$31,721
$32,913
$35,775
$47,700
$59,625
$71,550
$95,400
5
$0 - $27,909
$27,910
$37,120
$38,516
$41,685
$55,820
$69,775
$83,730
$111,640
6
$0 - $31,979
$31,980
$42,520
$44,119
$47,995
$63,940
$79,925
$95,910
$127,880
7
$0 - $36,029
$36,030
$47,920
$49,721
$54,045
$72,060
$90,075
$108,090
$144,120
8
$0 - $40,089
$40,090
$53,320
$55,324
$60,135
$80,180
$100,225
$120,270
$160,360
$4,060
$5,400
$5,603
$6,090
$8,120
$10,150
$12,180
$16,240
For each
additional
person, add
Effective 4/1/2014-3/31/2015
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Course Name: Eligibility for Individuals and Families
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4 COVERED CALIFORNIA ELIGIBILITY REQUIREMENTS
WHO CAN APPLY FOR COVERAGE?
Any California resident can apply for health insurance coverage through Covered California
regardless of their tax household income or whether they currently have health coverage. To be
eligible to apply, a consumer must be:

A California resident (or a person who intends to reside in California). Consumers are
required to provide their address on the online application as part of the eligibility
verification process

A US citizen, US national, or lawfully present in the US

Not incarcerated
Immigrants who are not considered lawfully present are not eligible to purchase a Covered
California health plan. However, they can still apply through Covered California to pre-screen for
health coverage options through Medi-Cal, but the benefits may be limited.
Incarceration Status and Eligibility
Consumers are not eligible for a Covered California health plan if they are incarcerated postdisposition (i.e., convicted of a crime and serving a sentence). However, individuals awaiting the
disposition of their charges are eligible. For example, a person who was arrested and is
awaiting trial is eligible to enroll in a Covered California health plan or Medi-Cal.
UNDERSTANDING LAWFUL PRESENCE, IMMIGRATION STATUS, DOCUMENTATION
AND ELIGIBILITY
US citizens, US nationals and individuals considered lawfully present have access to affordable,
quality coverage through Covered California. Depending on income, they may be eligible for
Covered California health plans with financial assistance or for low- or no-cost coverage through
Medi-Cal. California residents who are not considered lawfully present are exempt from the
requirement to have health insurance and can file for an exemption directly with the IRS. They
can also use Covered California to see if they are eligible for limited or reduced-scope health
coverage options through Medi-Cal.
The following tables include, but are not limited to, the most common definitions of US citizens,
US nationals and lawfully present individuals. The tables also describes the valid documentation
required to determine program eligibility.
Status Definition
Valid Documentation
Program Eligibility
 Social Security Number
 Covered California health
plan, with or without
financial assistance
 Full-scope Medi-Cal
US Citizen or US National
Born in the US or a person
who owes permanent
allegiance to the US (i.e.
those born in American
Samoa or Swains Island)
US Naturalized Citizen
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Status Definition
Valid Documentation
Program Eligibility
Person has been
naturalized as a US citizen
(became a US citizen after
birth)
 Certificate of
Naturalization (N-550 or
N-570)
 Certificate of US
Citizenship (N-560 or
N-561)
 Covered California Health
Plan, with or without
financial assistance
 Full-scope Medi-Cal
Status Definition
Valid Documentation
Program Eligibility
Depending on individual’s
situation:
 Green card number
(Resident Alien Number)
with expiration date (I551)
 Reentry Permit (I-327)
 Refugee Travel
Document (I-571)
 Employment
Authorization Card (I766)
 Machine Readable
Immigrant Visa (with
temporary I-551
language)
 Temporary I-551 Stamp
(on passport or I-94/I94A)
 Arrival/Departure
Record (I-94/I-94A)
 Arrival/Departure
Record in foreign
passport (I-94)
 Foreign Passport
 Certificate of Eligibility
for Nonimmigrant
Student Status (I-20)
 Certificate of Eligibility
for Exchange Visitor
Status (DS2019)
 Notice of Action (I-797)
 Covered California health
plan, with or without
financial assistance
 Full-scope Medi-Cal for:
o Individuals up to 21
years of age
o Pregnant individuals
with income up to
60% of the federal
poverty level (FPL)
o Children in families
with income up to
266% of the FPL
o Parents, seniors, and
persons with
disabilities
o Parents and
caretakers with
income up to 138% of
the FPL
o Adults without
children, ages 19 to
64, with income up to
138% of the FPL
 Pregnancy-only Medi-Cal
for:
o Qualified immigrants
who are pregnant
with income of 60%213% of the FPL
Lawfully Present Individuals
 Qualified noncitizens/immigrants:
o Lawful permanent
residents (LPR/Green
Card Holders)
o Asylees
o Refugees
o Cuban/Haitian
entrants
o Individuals paroled
into the US for at least
one year
o Individuals with
conditional entry
granted before 1980
o Battered non-citizens,
spouses, children, or
parents
o Victims of trafficking
along with their
spouses, children,
siblings, or parents, or
individuals with a
pending application
for a victim of
trafficking visa
o Individuals granted
withholding of
deportation
o Members of federally
recognized Indian
tribes or American
Indians born in
Canada
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Covered California Participant Guide
Course Name: Eligibility for Individuals and Families
Status Definition
Valid Documentation
 Humanitarian statuses
or circumstances
(including Temporary
Protected Status,
Special Juvenile Status,
asylum applicants,
Convention Against
Torture, victims of
trafficking)
 Valid non-immigrant
visas
 Legal status conferred
by other laws (temporary
resident status, LIFE
Act, Family Unity
individuals)
 Individual with a work or
student visa who intends
to become a permanent
resident of California






Version 3.0
Program Eligibility
Document indicating
membership in a
federally recognized
Indian tribe or American
Indian born in Canada
Certification from US
Department of Health
and Human Services
(HHS) Office of Refugee
Resettlement (ORR)
Office of Refugee
Resettlement (ORR)
eligibility letter (if under
the age of 18)
Document indicating
withholding of removal
Administrative order
staying removal issued
by the Department of
Homeland Security
Alien number (also
called alien registration
number or USCIS
number) or 1-94 number
The following table lists the status definition, required documentation and program eligibility for
those individuals who are temporary residents:
Status Definition
Valid Documentation
Program Eligibility
Temporary residents (who do not intend to reside in California)
 Foreign visitors
 Students with
temporary visas
 Individuals with
temporary visas
 Employment
Authorization Card (I766)
 Temporary I-551 Stamp
(on passport, I-94, or I94A)
 Arrival/Departure
Record (I-94, I-94A)
issued by USCIS
 Certificate of Eligibility
for Nonimmigrant (F-1)
Student Status (I-20)
 Certificate of Eligibility
for Exchange Visitor (J1) Status (DS2019)
 Covered California health
plan, with or without
financial assistance. Must
reside in California for, and
file taxes in, the benefit
year.
 Restricted-scope Medi-Cal
Note: The preceding list is not exhaustive, but it does provide the most common immigration
statuses for lawful presence.
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No Five-Year Waiting Period for Lawfully Present Individuals
Unlike the federal requirements for Medicaid, there is no required five-year waiting period in
California for lawfully present individuals to be eligible for Medi-Cal. For example, under current
Medi-Cal policy, eligible green card holders can receive full-scope Medi-Cal coverage in
California even if they have been in the US for less than five years. California uses state funds
to provide these benefits during the “five-year period” versus federal funds.
Helpful Resources
For more information on the legal requirements for lawful presence, including the
definition of qualified immigrants, go to:

http://www.law.cornell.edu/cfr/text/45/152.2

http://www.law.cornell.edu/uscode/text/8/1641
Another helpful resource is the following report: “Lawfully Present Individuals
Eligible under the Affordable Care Act,” published by the National Immigration Law
Center (September 2012): www.nilc.org/document.html?id=809.
Requirement to Buy Health Coverage
US citizens, US nationals, or lawfully present individuals need to enroll in health coverage by
the end of open enrollment. If they do not have health coverage by this date, and do not qualify
for an exemption from the Department of Health and Human Services, they must pay a tax
penalty when they file taxes in April of that tax year. Individuals who are not lawfully present are
exempt from the requirement to have health insurance and will file for their exemption directly
with the IRS.
Mixed Immigration Status Families’ Options for Care and Coverage
Many immigrant families are of mixed status, with members having different immigration and
citizenship statuses. The concept of mixed status if often confused with mixed program families
which refers to households with members that qualify for both Covered California and Medi-Cal.
Mixed status families however, only refers to households with individuals who have different
immigration statuses.
Both lawfully present individuals and individuals not considered lawfully present can apply
through Covered California because they may be eligible for health coverage options through
Medi-Cal. Individuals not considered lawfully present may also apply for coverage for their
lawfully present family members (such as a dependent, US citizen child) who may be eligible for
coverage through a Covered California health plan or low or no-cost coverage through MediCal. Only the immigration status of the person who is seeking the health coverage (in this case,
the dependent US citizen child) would be needed.
For questions about the Covered California health plans available, mixed-program families can
call the Covered California Service Center at (800) 300-1506. Covered California will be able to
answer questions about its own plans and can transfer those with questions about Medi-Cal
plans to the appropriate resource. Consumers can also call Medi-Cal Health Care Options staff
directly at 800-430-4263 for questions about Medi-Cal plans.
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VERIFYING RESIDENCY, INCARCERATION, CITIZENSHIP AND IMMIGRATION STATUS
FOR COVERED CALIFORNIA HEALTH PLANS
Only individuals planning to enroll in a health plan through Covered California who have stated
they are a citizen, national, or lawfully present will be asked for verification information regarding
their citizenship or immigration status (such as a Social Security Number or Alien Number).
Undocumented individuals who are not eligible themselves for coverage through a Covered
California health plan may apply for family members who are eligible. Non-consumers should
not be asked for their citizenship or immigration status when applying for a family member.
Undocumented individuals may also apply for an eligibility determination for themselves through
Covered California as they may be eligible for Medi-Cal, as described in the next section.
Covered California verifies a consumer’s attestation of citizenship using available data from the
Social Security Administration and the Department of Homeland Security. The following table
lists the sources used to verify various consumer information. These sources make up Covered
California’s federal hub.
Eligibility Factor
Data Source Used to Verify Eligibility or Consumer’s
Attestation
Social Security Number
Social Security Administration
Citizenship


Social Security Administration
Department of Homeland Security
Immigration Status
Department of Homeland Security
Residency
Consumer attestation is accepted unless the information does not
match other information available to Covered California
Incarceration Status
Attestation is accepted as provided in the application unless the
information does not match other information available to
Covered California
Income


Department of Treasury
Current data sources (i.e. IRS)
Minimum Essential
Coverage (MEC)


Department of Health and Human Services (Federal)
Department of Health Care Services (State)
5 MEDI-CAL HEALTH COVERAGE AND ELIGIBILITY
MEDI-CAL ELIGIBILITY OVERVIEW
Medi-Cal offers low or no-cost health coverage for California residents who meet eligibility
requirements. It is California’s Medicaid program, financed with both federal and state funding,
governed by the Department of Health Care Service (DHCS), and each county in California is
responsible for operation of the program at the local level. Medi-Cal is comprised of different
sub-programs that specifically target populations in California that are in need of health care
services.
Effective January 1, 2014, California expanded Medi-Cal eligibility for some low-income adults.
When a consumer completes the Covered California application they will be automatically
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reviewed for Medi-Cal eligibility. Like Covered California, Medi-Cal will use MAGI to determine
program eligibility.
As part of the Medi-Cal expansion, the Targeted Low-Income Children’s Program (TLICP)
replaced what was known as the Healthy Families Program. TLICP is a low-cost insurance
program for children and teens that provide health, dental, and vision coverage to children who
do not have health insurance.
Individuals seeking Medi-Cal coverage fall into one of two major groups:
EXPANDED MEDI-CAL GROUP
Expanded Medi-Cal refers to Medi-Cal programs that follow MAGI rules for determining income
eligibility and is also referred to as MAGI Medi-Cal. An asset test is not required for this new
coverage group. The following table outlines income eligibilities for Expanded Medi-Cal groups:
MAGI Group
Description
Income Limit
Childless adults
Between the ages of
19 and 64
Up to 138% of FPL
Parents and
caretaker relatives
Parents and caretaker
relatives of a
dependent child
Up to 138% of FPL
Children
Infants and children
under age 19 (or 21 if a
full-time student)

Infants (< 2 years old): Up to
266% of FPL (266 – 322% of FPL
for the Medi-Cal Access Program
 Children: Up to 266% of FPL
Pregnant individuals
Pregnant and postpartum women eligible
for pregnancy services
or full-scope benefits
 Up to 213% of FPL
 Also, those with income:
o Up to 60% of FPL are eligible for
full-scope Medi-Cal
o From 60% – 213% of FPL are
eligible for coverage of pregnancyrelated services
o From 100% – 400% of FPL can also
choose to enroll in Covered
California and receive premium
assistance
o From 214% – 322% of FPL are
eligible for the Medi-Cal Access
Program.
OTHER MEDI-CAL GROUP
Other Medi-Cal groups, often referred to as Non-MAGI Medi-Cal applies to existing participants
and programs that do not follow MAGI rules for determining income. An asset test is continued
to be required for Medi-Cal beneficiaries.
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Categories includes, but are not limited to, the following individuals:

Ages 65 and older

Blind

Disabled according to Social Security Administration rules

Supplemental Security Income (SSI)/State Supplementary Payment (SSP) recipients

Recipients of refugee assistance

Receiving long-term care (LTC) in a skilled nursing or intermediate care home

Home and Community Based Waiver recipients

Medicare Savings Program participants

Enrolled in California Work Opportunity and Responsibility to Kids (CalWORKS)

Enrolled in a foster care or adoption assistance program
FORMER FOSTER CARE CHILDREN’S PROGRAM
Effective January 1, 2014, the Former Foster Care Children’s Program (FFCCP) will extend
coverage to youth up until their 26th birthday, who were in foster care on their 18th birthday,
regardless of income. If an applicant previously aged out of the FFCCP, but is under the age of
26, the applicant still qualifies for Medi-Cal benefits up until their 26th birthday. The FFCCP
coverage group does not go through the MAGI determination of income. Program eligibility is
solely based on:

Participation in foster care in ANY state on their 18th birthday

Currently residing in the state of California

Younger than the age of 26
Beneficiaries who aged out of foster care and are not currently enrolled in Medi-Cal can apply at
their local county social services office. When an application is submitted, the applicant’s
participation in foster care on their 18th birthday will be verified. If verification cannot be
confirmed at the time of application, the applicant must enroll based on self-attestation. The
county social service office has 30 days to verify participation in foster care.
Former foster care youth who are unsure of their foster care status on their 18th birthday should
call the Foster Care Ombudsman at (877) 846.1602 or email [email protected].
County-specific information for assistance can be found at:
http://www.childrennow.org/uploads/documents/Coveredtil26_CountyContactList.pdf
CITIZENSHIP AND IMMIGRATION STATUS FOR MEDI-CAL ELIGIBILITY
Citizenship or lawfully present immigration status is not a requirement for Medi-Cal eligibility.
However, immigration status will determine the type of eligible services an individual may
access. To be eligible for full-scope Medi-Cal a consumer must be a US citizen, a US national, a
qualified alien in the US, or Permanently Residing Under the Color of Law (PRUCOL) (including
Deferred Action for Childhood Arrivals (DACA)).
Eligibility Requirements for Individuals Not Lawfully Present in the US
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The following table lists the status definition, required documentation and program eligibility for
those individuals who are not lawfully present in the US or are temporary residents:
Status Definition
Valid Documentation
Program Eligibility
Not Lawfully Present Individuals
 Permanently Residing
Under the Color of Law
(PRUCOL)
 Deferred Action for
Childhood Arrival (DACA)
 PRUCOL - documentation from
United States Citizenship and
Immigration Services (USCIS)
showing PRUCOL status
Full-scope Medi-Cal
 DACA - Form I-210, Form I-797
Notice of Action or a letter or
indicating that the alien’s departure
has been deferred. Employment
Authorization Document (Card),
Form I-766) with status code “C-33”
Eligibility for Undocumented Immigrants
Undocumented immigrants are not eligible for full-scope Medi-Cal coverage or for coverage
through a Covered California health plan. However, if all other requirements are met, including
residency, they are eligible for restricted-scope Medi-Cal coverage as the following table
outlines:
Status Definition
Valid
Documentation
Program Eligibility
Undocumented Immigrants
A foreign-born
person who does not
have a legal right to
be or remain in the
US
Not applicable
 Restricted-scope Medi-Cal:
o Emergency-related services
o State-funded long-term care
(LTC)
o Pregnancy-related services:
 Prenatal care
 Labor and delivery
 Up to 60 days of post-partum
care
 Family planning services
 Long-term care/kidney dialysis
 Medi-Cal Breast and Cervical Cancer
Treatment Program (BCCTP)
 The Medi-Cal Access Program
 Family Planning Access, Care, and
Treatment (Family PACT)
 Child Health and Disability Prevention
Program (CHDP)
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CALIFORNIA MEDI-CAL RESIDENCE REQUIREMENTS
To be eligible for Medi-Cal, a consumer must reside in California. Consumers will attest to their
address on their online application, which will be used in the verification process. If further
address verification is required the following is a list of currently acceptable types of proof of
residency for Medi-Cal:







Recent rent or mortgage receipt, or utility bill in the individual’s name
Current motor vehicle driver’s license or identification card issued by the California
Department of Motor Vehicles in the individual’s name
Current California motor vehicle registration in the individual’s name
A document showing that the individual is employed or is seeking employment in
California
Evidence that the individual has enrolled their children in a school in California
Evidence that the individual is receiving public assistance in California
Evidence of registration to vote in California
NO FIVE-YEAR WAITING PERIOD IN CALIFORNIA FOR LAWFULLY PRESENT
INDIVIDUALS
Unlike the federal requirements for Medicaid, to be eligible for Medi-Cal, there is no required
five-year waiting period for lawfully present individuals. For example, under current Medi-Cal
policy, eligible green card holders can receive full-scope Medi-Cal coverage in California even if
they have been in the US for less than five years.
MEDI-CAL ELIGIBILITY DETERMINATION FOR HOUSEHOLD INCOME AND SIZE
MAGI Eligibility Determination
Effective January 1, 2014, federal law modified the way California calculates tax household
income for determining Medi-Cal eligibility.
Determining MAGI Medi-Cal Eligibility
Population
Income Threshold*
Childless adults, parents and
caretaker relatives
138% of the FPL
Pregnant women
213% of the FPL
Children
266% of the FPL
*Includes the 5 percent income variant disregard
NOTE: Under MAGI rules, assets are not considered when determining eligibility.
Household Size Determination for Medi-Cal
Although MAGI is also used to determine eligibility for financial assistance for Covered
California health coverage, household size determination differs slightly between Covered
California and Medi-Cal:

For Covered California eligibility, the household always consists of the tax filer and
all tax dependents.
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
Version 3.0
For Medi-Cal eligibility, the household may be different from the tax filing unit for
three reasons:
1. Married couples living together are always considered to be in the same
household whether they file taxes jointly or separately.
2. Children are always considered part of the household in which they live with their
parents and siblings, regardless of who claims them as tax dependents.
3. Medi-Cal has special rules for counting pregnant women that include the number
of children expected. Thus, a pregnant woman expecting twins in her third
trimester could be counted as one person under the Covered California
APTC/CSR rules and as three people under Medi-Cal rules.
ELIGIBILITY DETERMINATION PROCESS
The following three-step process is used to determine whether a consumer is eligible for MediCal:
1. Identify the members of the consumer’s family
2. Add the income of qualified household members
3. Compare total tax household income to the FPL
(Note: There are some additional modifications to MAGI that are made when determining MediCal eligibility)
Income Limits
The program income limits vary for different coverage groups for Medi-Cal. For example,
children and pregnant women qualify for Medi-Cal at higher income guidelines compared to
childless adults.
The following table outlines the eligibility income guidelines for Medi-Cal groups:
Determining Medi-Cal Eligibility
Population
Income Limit (up to)
Childless adults (no biological children)
138% of the FPL
Parents and caretaker relatives
109% of the FPL
Pregnant women
213% of the FPL
Children
266% of the FPL
If a family’s tax household income is above the limits for Medi-Cal the applicant will be
determined for Covered California with or without financial assistance.
Example: Derek and Michelle are married and seeking coverage for themselves and their 9
year old daughter, Sofia. Michelle is seven months pregnant and recently lost her employersponsored coverage due to a layoff. Derek is a landscaper and his projected annual income is
$45,000 (225 percent of the FPL). When submitting their Covered California application the
family will qualify for different programs. Derek will most likely qualify for Covered California with
financial assistance, Michelle will qualify for pregnancy-related coverage through Medi-Cal and
Sofia will qualify for Medi-Cal’s TLICP. All programs offer different levels of coverage with
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different out-of-pocket expenses, and satisfy the requirement to have minimum essential
coverage.
ENROLLMENT PERIOD AND APPLICATION PROCESSING TIMES
Consumers who are eligible for Medi-Cal may apply for coverage during any month of the year;
there is no enrollment deadline. In household in which some members qualify for Medi-Cal and
other qualify for Covered California, only one application needs to be completed. It is important
to note that consumers, including dependents, who are eligible for Medi-Cal and fail to enroll will
also be subject to the tax penalty for being uninsured.
Consumers who successfully enroll into Medi-Cal are eligible for the entire month in which they
were found eligible. In some cases, consumers may be able to get coverage right away.
However, if a consumer is trying to enroll some household members in Medi-Cal and others in a
Covered California health plan, enrollment in Covered California only occurs during the openenrollment period (unless a qualifying event allows for an application to be submitted during
special enrollment).
Note
Some individuals who qualify for Medi-Cal coverage may be eligible for payment of their
medical bills up to three months prior to the date of their Medi-Cal application through
Retroactive Benefits.
When a consumer is determined eligible for Medi-Cal in a given month, eligibility is in effect for
that entire month. In some cases, the consumer may be able to receive Medi-Cal coverage
immediately. Consumers whose application requires resolution regarding citizenship or
immigration status will be classified as conditionally eligible for Medi-Cal coverage. For more
information on eligibility, contact the county’s Health and Human Services Agency at
http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.
Application Processing Times
The Medi-Cal eligibility determination process is completed as quickly as possible, with a
targeted timeframe of:
 45 days following the date of the application or reapplication is filed
 90 days following the date of the application or reapplication is filed when eligibility
requires establishing disability or blindness
The 45/90-day time period starts on the date of the application, including mail-in applications.
Applications are excluded from the 45/90-day minimum processing requirement if the consumer
provides partial information or fails to comply with requests for additional information/verification
documentation.
PRESUMPTIVE ELIGIBILITY PROGRAMS
Medi-Cal offers programs that provides consumers with temporary immediate coverage before a
consumer is formally determined eligible to enroll in a Medi-Cal program. These programs grant
consumers with presumptive eligibility (PE), meaning they are considered eligible until
determined otherwise.
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Hospital Presumptive Eligibility Program
On January 1, 2014, the hospital presumptive eligibility (PE) program began providing
individuals with temporary, no cost Medi-Cal benefits for up to two months. The following
individuals may be eligible for hospital PE benefits:




Children ages 0-18
Parents and caretaker relatives
Pregnant women
Former foster care children 18 to 26 years of age who were in foster care on their
18th birthday
 Adults ages 19-64, not pregnant, not on Medicaid, and not part of any group
described above
To receive hospital PE benefits, an individual must submit a simplified application online during
their hospital stay. Individuals will be notified immediately of their eligibility determination. Also,
they will have the opportunity to complete the Covered California online application to ensure
that their benefits do not expire after the two-month coverage period. Inquiries regarding the
hospital PE program may be directed to: [email protected].
Presumptive Eligibility for Pregnant Women
Presumptive eligibility for pregnant women is a no cost Medi-Cal program designed to provide
immediate, temporary coverage for prenatal care to low-income pregnant women pending
submission of a formal Medi-Cal application.
Any woman, who thinks she is pregnant, has a tax household income at or below 213 percent of
the FPL and does not have an existing Medi-Cal case may qualify for PE coverage. However,
she must seek care through a participating PE provider. PE is temporary coverage up to 2
months (during the month the women applies for PE through the end of the following month).
PE coverage offers specific out-patient prenatal care, out-patient abortion procedures,
prescription drugs for conditions related to pregnancy, and limited preventive dental services.
However, it does not cover labor and delivery, family planning or inpatient care. Therefore, PE
patients must submit a formal Medi-Cal application to continue receiving coverage. For
questions about the PE program, contact the PE Support Unit at (800) 824-0088.
Medi-Cal Express Lane Eligibility
Express Lane Eligibility is a result of federal guidance to streamline Medi-Cal enrollment for
newly eligible adults and children. Newly eligible adults and children currently enrolled in the
CalFresh program who are not receiving Medi-Cal will use Express Lane Eligibility to expedite
the Medi-Cal enrollment process.
A federal waiver allows DHCS to grant Medi-Cal eligibility without the need for an application or
a determination for 12 months by using CalFresh income eligibility for enrolled adults and
children. By being enrolled in CalFresh, income and residency has been established and DHCS
will only need to conduct necessary citizenship and identity verifications to comply with federal
Medicaid regulations. For more information on Express Lane Eligibility please visit:
http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/ExpressLane.aspx.
MEDI-CAL ESTATE RECOVERY PROGRAM
Because Medi-Cal pays for medical care for some people whose savings and income are too
low for them to be able to pay for their own care, the cost of the consumer’s medical care or the
cost of the premiums paid for care may be required to be repaid to Medi-Cal upon the
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consumer’s death. Repayment is never more than the value of the assets the consumer had at
the time of death. The amount repaid can then be used to pay for medical care for others who
need it.
After receiving notification regarding the death of a person who received Medi-Cal benefits, the
Department of Health Care Services (DHCS) will decide whether or not the cost of services
must be paid back. Also considered, is the amount that has been paid by Medi-Cal and what is
left in the estate of the deceased who received services. Regardless of what is owed in
services, the total value collected will never be more than the value of assets owned by the
consumer at the time of their death.
The DHCS cannot require reimbursement under the following circumstances:


During the lifetime of a surviving spouse
For Medi-Cal services provided before the consumer’s 55th birthday (unless the
consumer is institutionalized)
 If the consumer is survived by a child under 21 years of age
 If the consumer is survived by a child who is blind or disabled (as defined by the
Federal Social Security Act)
 The result of reimbursement would cause substantial hardship to the deceased
dependents, heirs or survivors
For more information on estate recovery please visit:
http://www.dhcs.ca.gov/formsandpubs/publications/Pages/BrochuresMedi-Cal.aspx
CHILD HEALTH AND DISABILITY PREVENTION PROGRAM
The Child Health and Disability Prevention (CHDP) is a federal and state supported heath
program that provides periodic health assessment for the early detection and prevention of
disease and disabilities for low-income children and youth. CHDP provides care coordination to
assist families with medical appointment scheduling, transportation, and access to diagnostic
and treatment services. Health assessments are provided by enrolled private physicians, local
health departments, community clinics, managed care plans, and some local school districts.
Children are eligible from birth through the age of 18 if not enrolled in Medi-Cal; Medi-Cal
participants are eligible up to the age of 21. Children in Head Start and Preschool programs are
also eligible. The CHDP income limit is up to 213 percent of the FPL, and assets or immigration
status are not taken into consideration. If a child qualifies for CHDP, there is no cost for services
to the family. The program offers periodic child health assessments/examinations, whose
frequency is determined by the child’s age, which include:










Health and developmental history
Complete physical examination
Oral health assessment
Nutrition assessment
Behavioral assessment
Immunizations
Vision screening
Hearing screening
Laboratory tests for anemia, blood, lead, tuberculosis, urine abnormalities, sexually
transmitted diseases, and other problems as needed
Health education and anticipatory guidance
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To access CHDP families must contact a CHDP provider. To find providers please visit:
http://www.dhcs.ca.gov/services/chdp/Pages/countyoffices.aspx.
CONCERNS OR COMPLAINTS
Consumers covered under regular (fee-for-service) Medi-Cal who have a complaint may contact
their local county social services office for help. For a complete listing of offices and phone
numbers, contact the DHCS, www.dhcs.ca.gov, or call (916) 445.4171. Consumers in a MediCal managed care plan may contact either the Medi-Cal Managed Care Ombudsman at (888)
452.8609, or the Department of Managed Health Care at (888) 466.2219, to report a complaint.
6 ELIGIBILITY AND ENROLLMENT FOR AMERICAN INDIANS AND
ALASKA NATIVES
There are special eligibility standards for American Indians and Alaska Natives, sometimes
referred to by the acronym (AI/AN). The term applies to any individual who is:

Is a member of a federally recognized tribe by the US Bureau of Indian Affairs (BIA), in
the US Department of Interior
The definition of Indian relative to its use regarding Covered California and the Affordable Care
Act is different than its use relative to other federally supported health services to American
Indians under Medi-Cal and CHIP. Therefore, enrollment assistance personnel should be aware
that individuals may be deemed an American Indian for one program and not the other, resulting
in different eligibility outcomes. For purposes of Covered California eligibility, American Indians
and Alaska Natives are recognized if they are:

A member of a federally-recognized tribe by the United States Bureau of Indian Affairs
(BIA) in the U.S. Department of the Interior

First or second descendants of tribe members as described in the point above

An Eskimo or Aleut or other Alaska Native

Considered by the Secretary of the Interior to be an Indian for any purpose.

Determined to be an Indian by the Secretary of Health, Education and Welfare in
collaboration with the Department of Health and Human Services
The following table summarizes the eligibility and enrollment standards as they are applied with
Covered California for American Indians and Alaska Natives:
Eligibility and Enrollment Standards for American Indians and Alaska Natives
Standard
Requirements
Eligible for cost-sharing elimination if:



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Tax household income is less than 300%
of FPL for the benefit (coverage) year
Enrolled in a Covered California health
plan
Receives care from another health care
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Eligibility and Enrollment Standards for American Indians and Alaska Natives
Standard
Requirements
Individual mandate tax penalty
Exempt under all circumstances
Enrollment periods
Can enroll year-round
May change coverage
Once a month
ELIGIBILITY FOR THE ELIMINATION OF COST-SHARING EXPENSES
American Indians and Alaska Natives who enroll in a Covered California health plan do not have
to pay copays or cost-sharing expenses if they expect to have a tax household income that
does not exceed 300 percent of the FPL for the benefit year during which coverage is
requestedi.
If these individuals are enrolled in a Covered California health plan, any cost-sharing is
eliminated if a service is provided directly by:

The Indian Health Service

An Indian tribe

A tribal organization or urban Indian organization

Through a referral under contracted health services
The table below describes the special Indian provisions for eligibility in health coverage options:
Health coverage option
Medicare
Medi-Cal
Who is eligible
Special Indian provisions
Over 65 years old. Also,
those of any age with kidney
failure
Under 138% of the FPL
No premium
No co-pay/deductible
Child Health Insurance
Program (CHIP)
Covered California health
plan
Children under 19 years of
age with family income
under 266% of the FPL
Under 65 years of age who
are not eligible for Medi-Cal
and CHIP
No premium
No co-pay/deductible
No co-pay/deductible*
(if income is below 300% of
the FPL or consumer
receives services through
an Indian Health Program)
*Special monthly enrollment
provisions are limited to
members of a federally
recognized tribe
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There is no CSRs for American Indians or Alaska Natives, who are members of a federally
recognized tribe, for any item or service received from an Indian Health Program including Tribal
and Urban Indian Organizations or through referral under contracted health services, regardless
of tax household income.
EXEMPTION FROM INDIVIDUAL MANDATE PENALTIES
American Indians, who are members of a federally recognized tribe or are eligible for services
through an Indian Health Service provider and Alaska Natives are exempt from individual
mandate (shared responsibility) tax penalties. Members of a federally recognized tribe can
access the exemption through the IRS.
Once granted, it is a lifetime exemption, unless tribal eligibility status changes. Further, the
exemption does not prevent the consumer from enrolling in Covered California, Medi-Cal or
other health coverage programs.
ENROLLMENT PERIODS
American Indians, from a federally recognized tribe, and Alaska Natives do not have the same
open-enrollment restrictions as the general population. They are able to enroll in health
coverage year round and may switch health plans up to once per month.

Allows for unrestricted navigation between Indian Health Service coverage and
Covered California in order to access care not available at Indian Health Service
providers, such as medical specialists, hospitals and surgical care.
 Allows for unrestricted navigation between health plans and metal tiers to access
different premium levels and provider networks based on medical need.
Enrollment and effective dates for American Indian/Alaska Natives follow the same guidelines
as other Covered California health plans (discussed previously in this course).
VERIFICATION OF STATUS
If a consumer attests that they are an American Indian or Alaska Native (or included in one of
the other categories defined above), Covered California must verify this attestation against
available data sources. If additional documentation is required, the consumer has 90 days to
provide it to Covered California. Acceptable documentation includes:

Tribal Identification Card

BIA Form

Certificate of Degree of Indian Blood (CDIB)
7 PROCESSES FOR REFERRALS, APPEALS AND COMPLAINTS
REFERRALS TO NON-COVERED CALIFORNIA HEALTH PROGRAMS
The online application through CoveredCA.com supports referrals to non-Covered California
health programs by asking, “Would anyone in the household like a referral to the local Health
and Human Services Agency for any of the following programs: CalWORKS or CalFresh?”
Consumers who answer “yes” will be provided the contact information for the nearest agency.
Their application will also be forwarded to CalWORKS/CalFresh, and these agencies will follow
up with the consumer to obtain additional information and help them apply for benefits. The
referral process also applies to cases where the consumer requests a referral for non-MAGI
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Medi-Cal coverage. For information on CalWORKS go to: http://www.cdss.ca.gov/calworks/ .
For information on CalFresh go to: http://www.calfresh.ca.gov/ .
CONSUMER APPEALS PROCESS
Covered California has an appeals process for consumers who disagree with any of the
following:

Their eligibility determination for a Covered California health plan or Medi-Cal coverage

Determination of the premium assistance amount or cost-sharing reductions they should
receive

Annual redetermination of eligibility

Eligibility determination for an individual mandate exemption based on: hardship,
religious beliefs, membership in a ministry, incarceration, being an American Indian or
Alaska Native
Appeals Process Steps
The appeals process steps are:
Step 1:
Consumers have 90 calendar days from the notice date of a Covered
California or Medi-Cal determination to submit an appeal.
Step 2:
Covered California/Medi-Cal has 90 calendar days from the date the appeal is
submitted to take the appeal under consideration and settle it accordingly.
(The 90-day time frame is dependent on federal regulators providing a
response to Covered California.) During this 90-day period, Covered California
will:
Step 3:

Work closely with the consumer to resolve the issue on an
informal basis

Schedule and hold a formal hearing to settle the appeal if the
appeal cannot be resolved on an informal basis
If consumers are not satisfied with the appeal hearing decision related to
premium assistance or cost-sharing reductions, they can file an appeal directly
with the DHHS.
SUPPORT FOR CONSUMERS WITH CONCERNS OR COMPLAINTS
Covered California is committed to supporting consumers who call the Covered California
Service Center at 800-300-1506 with any concerns or complaints. There are a number of other
California state resources available to support consumers.
The Office of Patient Advocate (www.opa.ca.gov). The agency’s toll-free number is 866-4668900. This state agency provides:

A very useful overview of the health care industry

A glossary of terms

Education in patient rights

A step-by-step guide that explains to consumers how to deal with a problem or file a
complaint against their health care insurance company
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California Department of Managed Health Care (DMHC) (www.dmhc.ca.gov): This state
agency oversees HMOs and some PPOs. Consumers can contact the DMHC if they have filed
a complaint against their health insurance plan because it denied coverage based on lack of
medical necessity, or regarding treatment that is considered experimental or investigational in
nature. The agency’s toll-free number is 888-466-2219.
California Department of Insurance (CDI) (www.insurance.ca.gov): This state agency handles
complaints against PPOs, and it functions in the same manner as the Department of Managed
Health Care. Consumers can file a complaint with the CDI against their PPO if coverage was
denied based on lack of medical necessity, or regarding a treatment that is considered
experimental or investigational in nature. The agency’s toll-free number is 800-927-4357.
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8 ENDNOTES
Code of Federal Regulations, Part 155 — Exchange Establishment Standards and Other
Related Standards Under the Affordable Care Act [45 CFR 155], § 155.350 (a)(ii)
i
Sources

MedlinePlus, a service of the US National Library of Medicine, National Institutes of
Health. Accessed at www.nim.nih.gov

www.dhcs.ca.gov for Medi-Cal benefits

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HealthRefor
mTranslationMAGI.pdf for Medi-Cal benefits information

Medi-Cal Program Guide Special Notice (SN) 13-09, Addendum A, December 09, 2013

National Health Law Program, Youth Law Center, October 2013 (for foster care youth
information)
http://www.healthlaw.org/component/jsfsubmit/showAttachment?tmpl=raw&id=00Pd0000
007APpIEAW
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