Immunization Requirement

[40-105.4]

Rule

CalWORKs parents/caretaker relatives must verify that all children under the age of six in the AU have received age-appropriate immunizations.

Age-Appropriate Immunizations

Age-appropriate immunizations are those recommended by the ACIP, the American Academy of Pediatrics, and the American Academy of Family Physicians.

The immunizations currently recommended for children under six years of age are:

Type of Immunization	Abbreviation(s)	Dose	Recommended at
Polio	OPV, TOPV, IPV, Sabin, Salk	1st 2nd 3rd 4th	2 months 4 months 6 - 18 months Before starting school (4 - 6 years)
Diphtheria, Tetanus and Pertussis	DPT, DTaP, DT	1st 2nd 3rd 4th 5th	2 months 4 months 6 months 15 - 18 months Before starting school (4 - 6 years)
Kinrix Combination Vaccine (DTaP and IPV combined)		Booster	4-6 years of age as a booster dose of DTaP and IPV
Measles, Mumps, and Rubella	MMR	1st 2nd	12 - 15 months Before starting school (4 - 6 years)
Varicella Virus Vaccine (chicken pox)Varicella Virus Vaccine (chicken pox)Varicella Virus Vaccine is only required for susceptible children, i.e. a child who has not already had the chicken pox. This vaccine may not be universally available at the present time.	VAR, VZV	1st	12 - 18 months
Hepatitis B		1st 2nd 3rd	At birth - 3 months 1 - 5 months 6 - 18 months
Hemophilus influenzae type b Hemophilus influenzae type b If any dose is given after 12 months, no further doses needed.	Hib	1st 2nd 3rd 3rd or 4th	2 months 4 months 6 months (may not be required) 12 - 18 months

The following immunization schedule is for children who did not receive any immunizations in their first year of life:

Visit	When	Immunizations Which Might Be Given
First Visit		Polio (or OPV, TOPV, IPV, Sabin, Salk) DTP (or DTaP) MMR Varicella (chicken pox or VAR, VZV) Hepatitis B Hib
Second Visit	1 - 2 months after 1st visit	Polio (or OPV, TOPV, IPV, Sabin, Salk) DTP (or DTaP) Hepatitis B Hib
Third Visit	1 - 2 months after 2nd visit	Polio (or OPV, TOPV, IPV, Sabin, Salk) DTP (or DTaP)
Fourth Visit	6 months after 3rd visit	DPT (or DTaP) Hepatitis B

Informing Requirements

At intake, annual redetermination and when adding a child under the age of six, all applicants and recipients must be provided with the “CalWORKs Immunizations Rules” (CW 101). The CW 101 informs the clients of:

Their obligation to secure immunizations for all children in the AU under the age of six and the penalty for failure to comply;
The age-appropriate immunizations;
The right to file an affidavit claiming that immunizations are contrary to their personal and/or religious beliefs or for medical reasons; and
How immunizations may be obtained through a fee-for-service provider that accepts Medi-Cal, a Medi-Cal managed care plan, or a county public health clinic.

Immunization Referrals

Eligibility Workers must ensure that the client knows where to get immunizations.

Enrolled in Managed Care

Applicants/Recipients shall be referred to his/her primary provider if the client is enrolled in a managed care plan. If the client does not know who the managed care plan or primary provider is, refer him/her to:

Maximus (Health Care Options): 1-800-430-4263
Santa Clara Family Health Plan: 1-800-260-2055
Blue Cross of California: 1-800-407-4627

Not Yet Enrolled in Managed Care

If the client is not yet enrolled in a managed care plan, refer to the immunization referral information provided on the “CalWORKs Immunization Rules” (CW 101).

Verification

Age-appropriate immunizations for children under the age of six must be verified:

At application,
At annual RD, and
When adding a child under six to the AU.

Intake

The “CalWORKs Immunization Rules” (CW 101) must be included in all CalWORKs intake packets.

At intake, EWs must review the CW 101 and request immunization verification for all children under six years of age.

Annual Redetermination

The “CalWORKs Immunization Rules” (CW 101) must be included in all CalWORKs RD packets. EWs must review the immunization records for all children under six years of age to ensure that the client is complying with the immunization verification requirement.

Example Example A medical doctor’s statement is not required annually when verification is on file that the child is exempt due to a permanent medical condition.

Inter-county Transfers (ICT)

When an AU has submitted adequate verification of age-appropriate immunizations in the sending county, verification is not required to be resubmitted to the receiving county.

Note: If the immunization verification on file in the case record indicates that the child meets the age appropriate requirements, additional verification is not needed.

Example Example The immunization verification on file indicates that the child had age-appropriate immunizations at the last RD when he/she was 18 months old. The child will be 2 1/2 years old at this years RD and, based on the recommended immunization schedule, was not required to receive additional immunizations during the last year. The immunization verification on file is still valid. Additional verification is not needed at this time.

Types of Verification

The following can be used to verify immunizations:

California Immunization Card (Yellow Card),
“Request for Verification of Immunization” (CSF 49), or
The California Immunization Registry 2 (CAIR2) system.

The Immunization Detail page must be completed for each child under the age of six in a CalWORKs AU.

California Immunization Record (Yellow Card)

The California Immunization Record (Yellow Card) is the primary document used to verify immunizations.

Note: The “Immunization Assessment Form” (SCD 832) is a tool that is available to evaluate the immunization record.

“Request for Verification of Immunization” (CSF 49)

The “Request for Verification of Immunization” (CSF 49) is used to verify age-appropriate immunizations when the yellow card is not available or does not verify age-appropriate immunizations.

The CSF 49 must be completed and signed by:

A medical provider (i.e. physician, authorized member of physician’s staff, public health department, etc.), OR
A public agency which requires age-appropriate immunizations (i.e. local school district, the Head Start Program, licensed day care center, etc.)

The child meets the immunization requirements if the CSF 49 indicates that the child has age-appropriate immunizations or is in the process of receiving age-appropriate immunizations. A copy of the immunization record is NOT needed. However, the parent/caretaker relative should be encouraged to keep and maintain the immunization record for his/her child(ren).

The CSF 49 must be used to verify an exemption due to medical reasons. When used to verify an exemption due to medical reasons, it must be signed by a medical provider.

California Immunization Registry 2 (CAIR2)

The California Immunization Registry 2 (CAIR2) is a confidential secure web-based system available to approved agencies to electronically verify immunizations when the yellow card or CSF 49 is not available or the documents provided do not verify age-appropriate immunizations.

The system allows users to do:

Retrieve immunization records and
Reprint California Immunization Records (yellow cards).

Verification Time Frames

The parent(s)/caretaker relative must provide verification of age-appropriate immunizations within the time frames given below:

If the family...	And...	Then verification must be provided within...
Is applying for Cal- WORKs	Is a current Medi-Cal beneficiary,	45 calendar days from the date of application.
Is applying for Cal- WORKs	Is also a new Medi-Cal applicant,	30 calendar days from the date of EW approval of Medi-Cal.
Receives CalWORKs		45 calendar days from the date of the face-to-face interview at RD.
Is adding a child under six to the AU,	The child is a current Medi-Cal beneficiary,	45 calendar days from the date of application for the child.
Is adding a child under six to the AU,	Is also being added to Medi-Cal,	30 calendar days from the date of EW approval of Medi-Cal.
The time frames listed above may be extended if good cause exists. Refer to Good Cause Criteria for additional information.

If immunization verification does not reflect age-appropriate immunizations, the EW must:

Provide the client with immunization referral information,
Ask the client to take the child for immunizations, and
Issue an “Request for Verification of Immunization” (CSF 49) indicating the due date.

Example Example Janet is already receiving Medi-Cal and applies for CalWORKs on 12/15. Immunization verification must be provided by 1/29 (45 calendar days from the date of application). The EW must create a case alert for follow-up before 1/29.

Example Example Christina applies for CalWORKs and Medi-Cal on 1/5. The case is approved on 1/10. Immunization verification must be provided by 2/11 (30 calendar days from the date of Medi-Cal approval). The Intake EW must secure verification if available. If not available prior to case transfer, then create a case alert for follow-up before 2/11.

Example Example Elizabeth, a CalWORKs recipient reports that her 5-year-old child returned home after spending several months with grandma and needs to be added to the AU. The child is not currently active on Medi-Cal. The EW schedules a face to face interview appointment with Elizabeth on 2/26 and approves CalWORKs and Medi-Cal for the 5-year-old child on 3/01. Immunization verification must be provided when the child is added to the AU or by 3/31 (30 calendar days from the date of Medi-Cal approval). The EW must create a case alert for follow-up before 3/31.

Exemptions

A child is exempt from the immunization requirements when the parent(s)/caretaker relative submits one of the following:

An affidavit stating that the immunization requirement is contrary to his/her personal/religious beliefs and the reasons for his/her objection. The parent(s)/caretaker relative must complete the “Immunization Good Cause Request Form” (CW 2209) by circling one or more boxes or completing the “other” section describing why the child has not been immunized.
A written statement from a physician or health professional, working under the supervision of the physician, stating that the child cannot be immunized due to medical reasons. The type of medical condition and duration is required to be included in the written statement.

Good Cause

When requested by the client, and prior to applying a penalty, the EW must determine if good cause exists. Circumstances which may constitute good cause may include, but are not limited to, the following:

Physical distance,
Language barriers,
Illness of the parent(s) or caretaker relative,
Bona fide transportation problems,
Lack of available appointments,
Religious beliefs,
Immunization needed was not available, or
Is the victim/survivor of past/present domestic abuse which has caused the inability to comply, or
Records do not reflect all of the immunizations that the child(ren) received and the parent or caretaker relative is trying to correct the records.

The CW 2209 must be provided to the client at intake, annual redetermination, and any time verification of immunizations is requested to claim good cause. The applicant/recipient may claim good cause by either:

Completing the CW 2209 or
By making a verbal request.

Reminder: All requests for good cause must be documented in Journal page.

In addition to good cause requests made by the client, the CW 2209 must be sent with all NOAs pertaining to any change in grant as a result of the failure to meet immunization requirements. When sending the CW 2209 with a NOA, the EW must include a self-addressed postage paid envelope, addressed to the EW, so that the client can return the requested verifications by mail, if they choose, without hardship.

Reminder: Clients are allowed to verbally inform the EW of their good cause request. Making a verbal request is the same as completing the CW 2209.

If it is determined that good cause exists, the applicant/recipient must be allowed an additional 30 days to submit immunization verification and any penalty being imposed must be suspended. The request must be documented on the Journal Detail page and a penalty must not be applied to the AU.

Good cause determinations must be reviewed at the next annual RD to evaluate completion of immunization requirement or identify if the AU meets an exemption or good cause criteria.

Good Faith Effort

If the applicant/recipient is attempting to meet immunization requirements, but is not able to meet them due to scheduling, transportation problems or unavailability of vaccines, the worker must not impose a penalty. The applicant/recipient shall be given an additional 30 days to submit immunization verification. EWs are required to assist applicants/recipients in obtaining necessary verification of immunizations.

A child is considered to have received age-appropriate immunizations when the parent(s)/caretaker relative has made a good faith effort to begin immunizations for the child, but the complete series has not been given because of a spacing requirement between vaccine doses.

Note: EWs should check the CAIR2 system to see if the immunization record is available online if, at the end of the 30 day period, the client has not provided proof of immunizations.

Penalty for Non-Cooperation

If the parent(s)/caretaker relative fails or refuses to verify that all children under the age of six have received age-appropriate immunizations and an exemption (see Age-Appropriate Immunizations) or Good Cause cannot be established, the parent(s)/caretaker relative must be penalized.

Penalties can only be applied to the natural or adoptive parent(s) or to the caretaker relative (i.e. needy caretaker relative). An adult in the AU who is not responsible for the child under six (i.e. step-parent or non-needy caretaker relative) cannot be penalized unless he/she is the caretaker relative.

Reminder: If the client is unable to provide the requested verifications, prior to imposing the penalty for non-cooperation, the EW shall assist the client in obtaining the necessary verifications.

Minor Parent Case

In a minor parent case, the aided senior parent is considered the responsible caretaker relative and is therefore penalized if age-appropriate immunizations are not verified for the minor parent’s child.

Procedure

Enter the immunization verification status on the Individual Immunization Detail page. CalSAWS will:

Reduce the grant by an amount equal to the needs of the parent(s)/caretaker relative, and
Continue to count the income and/or property of the penalized individuals.

Note: If both parents are in the AU, then both parents must have the penalty applied.

Removing A Penalty

CalSAWS will automatically end the immunization penalty effective the first of the following month in which a child turns six.

EWs must manually remove the immunization penalty the first of the following month in which:

Verification of age-appropriate immunization is submitted to the county, or
An exemption is met.

Example Example Janet must provide age-appropriate immunization verification for her 3-year old child by 1/29. Verification is not provided by the due date and Janet has not made contact with her EW. The EW applies a penalty to the AU, issues a 10-day NOA and reduces the March CalWORKs grant. On 5/16, Janet submits age-appropriate immunization verification to her EW. The EW removes the penalty effective 6/1.

The EW must verify that the penalty for a child, who turns six years, is ended the month prior to the child's birthday. Benefits must be restored the first day of the month in which the child turns six.

Example Example A child’s sixth birthday is June 5th. The penalty must be removed in the month of May and benefits restored effective June 1st.

Multiple Children in the AU

EWs must manually enter the end date of the immunization penalty as the month prior to the youngest child’s sixth birthday when there are multiple children under the age of six missing verification. The penalty must be lifted when the youngest child turns six, unless verifications have been provided for all applicable children.

Documentation/Journal Entries

EWs must document the following in the Journal Detail page at intake, annual redetermination, or when adding a child under 6 years old:

Verification of immunization,
Determination of good cause and the reason, or
Exemption to the immunization requirement and the reason for the exemption.

Intercounty Transfers (ICTs)

When an AU moves from one county to another and an ICT is being processed, verification of age-appropriate immunizations that has been accepted in the sending county is considered acceptable in the receiving county.

Outgoing ICTs

When sending an outgoing ICT, note on the “Notification of Intercounty Transfer” (CW215) if an Immunization penalty has been applied and for which child(ren).

Incoming ICTs

The EW must contact the other county to request a copy of the immunization verification or review the California Immunization Registry 2 (CAIR2) system rather than issue a “Request for Verification of Immunization” (CSF 49) when processing an ICT if the client cannot readily provide the “Yellow Card.”

Procedures

The EW must follow the chart below to verify age-appropriate immunizations:

Review the case to determine if the AU contains a child under the age of six. If yes, continue. If no, immunization verification not needed.
Inform the CalWORKs applicant/recipient of the immunization requirement, including penalties and exemptions and provide the “CalWORKs Immunization Rules” (CW 101).
Verify immunization exemptions and/or good cause request:
1. Medical Exemption - Documentation from a medical provider which indicates the type and duration of the medical condition.
2. Personal/Religious Beliefs Exemption - Written statement on a “Sworn Statement” (GEN 853).
3. Good Cause Request- Completed “Immunization Good Cause Request Form” (CW 2209) on file.
4. Additional action is not required until the next RD. Immunization verification is only required at the next RD if the exemption verification on file is no longer valid.
Review the “Yellow Card” to determine if the child(ren) has received age-appropriate immunizations.
1. If age-appropriate immunizations are verified:
  1. Compare the immunization record to the Immunization Chart.
  2. Image the “Yellow Card” to the case.
  3. No additional action is needed until the next RD.
2. If the Yellow Card is not available or does not verify age-appropriate immunizations:
  1. Issue the Immunization Verification Form (CW 107).
Approve CalWORKs application/redetermination if all other conditions of eligibility are met. Create a case reminder for a 30/45 calendar day follow-up:
1. 30 calendar days from the date of Medi-Cal approval if the child is applying for Medi-Cal and CalWORKs at the same time. (Most intakes)
2. 45 calendar days from the date of the CalWORKs application if the child is already a Medi-Cal beneficiary.
3. 45 calendar days from the date of the interview at RD if the child is a CalWORKs recipient. (Most RDs)
Review the Immunization Verification Form (CW 107) to determine if the child(ren) has received age-appropriate immunizations.
1. Compare the immunization record to the Immunization Chart and if age-appropriate immunizations are verified:
  1. Image the to the case, and
  2. No additional action is needed until the next RD.
2. If the CW 107 is not returned or does not indicate age-appropriate immunizations, determine good cause if requested by the client.
If good cause exists, allow the parent(s)/caretaker relative an additional 30 days to submit the verification. Set a reminder to the case for a 30 day follow-up.
1. If good cause does not exist, a penalty will be applied to the AU. A 10 day NOA is required to reduce the CalWORKs grant.
When age-appropriate immunizations are verified or an exemption claimed or the child turns six, the penalty must be removed effective the first of the following month in which the verification is provided and the appropriate NOA issued.