Medi-Cal Referral Criteria

Who is Referred

A referral for securing medical support from the parent, or to establish paternity, is made for all children under 18 years of age when:

The minor child, whether married or unmarried, is eligible for and receiving Medi-Cal benefits and has an absent parent(s)

OR

The child is living with unmarried parents and paternity has never been established by either a court order or completion of a voluntary "Declaration of Paternity" (CS 909) form which has been signed and filed appropriately.

Reminder: A 14 to 18 year old not living in the home of a parent or caretaker relative and who does not have a parent, caretaker relative, or legal guardian handling any of his/her affairs is considered an adult and is NOT referred to the DCSS for child support recoupment.

Example 1Example 1 A 17-year old is eligible for Medi-Cal benefits, living with his caretaker mother; his father is absent. A referral for medical support is made on his absent father.

Example 2Example 2 A 5-year old child is eligible for Medi-Cal benefits; he lives with both his parents, who are unmarried. A medical support referral is made to establish paternity for the 5-year old child.

Example 3Example 3 A 19-year old child is living with his father; both father and son receive Medi-Cal benefits; the mother is absent from the home. A referral for medical support is NOT made on the absent mother, as the child is 18 years or older.

Who is NOT Referred

DO NOT make a referral for medical support when the Medi-Cal eligible person under 18 years of age is:

An unborn
A child applying for Minor Consent Services
An undocumented child, unless there is reasonable belief that the absent parent is a citizen
A child receiving AAP
A child with a single adoptive parent
A child removed from parental custody by court order
Provided OHC by the absent parent. (If there are two absent parents, refer any parent who is not providing OHC.) A PATERNITY referral is still required.
An infant during the 365-day postpartum period
Not receiving Medi-Cal benefits but included in the Medi-Cal case for linkage/deprivation purposes
An adult child.
- Refer to Medi-Cal Handbook, “Child,” for the definition of an adult child.
- Reminder: Immediately refer an absent parent for medical support when it is known that he/she is no longer providing OHC to the child.
Receiving TMC (Aid Codes 39/3T and 59/5T), or Four-Month Continuing (Aid Code 54/5W).
Receiving Edwards v. Kizer (Aid Code 38) Medi-Cal. Medical support requirements apply if the recipient wants continuing Medi-Cal. If a referral for medical support is required (for example, due to change in deprivation, or a referral was not previously completed), send the medical support forms to the recipient and set an alert for the return of the forms. A face-to-face interview with the recipient is not required to fulfill medical support requirements. If the required forms are not returned, discontinue the parent’s (or caretaker relatives’) Medi-Cal for failure to cooperate in the medical support enforcement process.
Approved for retroactive Medi-Cal Only, AND the parent or caretaker relative does not want any child support services.
Approved for Medi-Cal (for example, for one month), but there is no continuing Medi-Cal eligibility, AND the parent or caretaker relative does not want any child support services.
The child of a parent who is incarcerated or institutionalized. (If there are two absent parents, REFER the second parent who is not incarcerated or institutionalized.) Refer to Medi-Cal Handbook, “Specific Institutional Programs,” for additional information.
- Important: Although these persons are exempt from a medical support referral, this does not change the requirement to identify and report other health coverage information by completing the "Health Insurance Questionnaire" (DHS 6155).

Exemption to Referral for Pregnant Women

NO referral for medical support or to establish paternity is made when a Medi-Cal eligible woman IS PREGNANT, until the end of her 365-day (12 month) postpartum period. The DHS has established this policy to ensure that pregnant women receive essential prenatal care. A referral to the DCSS might otherwise discourage her from applying for Medi-Cal. If a woman becomes pregnant AFTER the EW completes a medical support referral, the DCSS will continue with medical support enforcement activities. However, the newborn child is not referred until the end of the 365-day postpartum period.

The following rules apply:

Medical support or paternity referrals are NOT made on the absent/unmarried parent of an unborn child until the end of the 365-day postpartum period of the caretaker pregnant parent.
Medical support or paternity referrals are NOT made on the absent/unmarried parent of other eligible children in the MFBU, until the end of the 365-day postpartum period of the caretaker pregnant parent. This rule applies, regardless of whether the absent/unmarried parent of the other eligible children is the same, or different, parent of the unborn.
The EW must not require the recipient to complete the medical support forms until the end of the 365-day postpartum period of the caretaker pregnant parent. Refer to "Referral at End of 365-Day Postpartum Period" below.
The pregnant woman who wishes to complete the CW 2.1 N&A and CW 2.1Q prior to the end of 365-day postpartum (for example, when the newborns’ birth is reported) may do so. However, the EW must not encourage the recipient to voluntarily do so. The referral is made at the end of the 365-day postpartum period.

ExampleExample A pregnant woman gives birth to her newborn on July 5, 2022. A referral for medical support is not made on the absent parent of her newborn, nor on any other eligible children, until August 1, 2023.

Continued Eligibility and Medical Support Referral for Newborn

A medical support referral is required at the end of the 365-day postpartum period. Even though increases in income and property from an unmarried father in the home do not affect a newborn when "Continued Eligibility" rules apply, DO NOT WAIT until the child reaches age one to make a medical support referral.

Referral at End of 365-Day Postpartum Period

Medical support/paternity referrals for child(ren) of pregnant women are deferred until the end of the 365-day postpartum period, when these procedures are followed:

When a pregnancy is reported (either to the intake or continuing EW), and there is an absent or unmarried parent, explain that:
1. A medical support or paternity referral is required at the end of the 365-day postpartum period.
2. The woman may also request child support enforcement from the DCSS, but it is not mandatory.
3. Forms will be sent to her at that time.
Create a task for the first of the month following the 365-day postpartum period: "Medical support or paternity referral due."
1. Important: Do not initiate a referral before the end of the 365-day postpartum period.
The first of the month following the 365-day postpartum period,
1. Send an "Appointment Notice and Brief Message to Client" (SCD 50) with the medical support forms to the recipient requesting the forms to be completed and returned.
2. Allow 10 calendar days for the return of all medical support or paternity referral forms. Enter the return due date on SCD 50.
  1. Reminder: A separate CW 2.1Q must be completed for each absent/unmarried parent. (EAS 82-510, CCR 50101, 50157, 50185)
When completed forms are returned and the CW 2.1 N&A indicates the recipient will cooperate with medical support:
1. Enter as much information as possible into the CalSAWS Absent Parents page.
2. Image the forms.
If the forms are returned and the recipient claims Good Cause for not cooperating with medical support enforcement:
1. Follow the Good Cause determination procedures. (EAS 82-510, CCR 50101, 50157, 50185)
2. Enter the Good Cause information into CalSAWS. Refer to Job Aid: Child Support Good Cause Claim for system entries.
3. Image the forms.
If the forms are not returned:
1. Enter the non-cooperation information into the Assign Medical Support Rights field of the Absent Parents page.
2. CalSAWS will discontinue only the parent or caretaker relative at the end of the month for "failure to cooperate with medical support requirements." A 10-day notice of adverse action is required.

Note: A parent or caretaker relative who is already an ineligible member of the MFBU remains as such. A parent or caretaker relative’s noncooperation does not affect the children. Children who are otherwise eligible continue to receive Medi-Cal benefits.

When to Make a Child Support or Paternity Referral

A referral to the DCSS to obtain medical support or to establish paternity must be made at the following times:

At intake. Clients shall be given 30 days from the time the packet was provided to comply with DCSS requirements. DCSS verifies active case status based upon CalSAWS information.
- Note: Do not make a medical support referral to the DCSS if the applicant is reapplying and the case has been closed less than one calendar month and a previous CalWORKs or Medi-Cal referral to the DCSS was already completed.
When restoring or adding to the MFBU an eligible child who has not been referred in the previous 12 months.
When transferring from CalWORKs to Medi-Cal Only, if a previous child support referral has not been made.
When CalWORKs deprivation changes from one linkage factor to absent parent linkage (i.e., deprivation changes from unemployed parent to absent parent).
At redetermination if:
- There is new information on a parent previously referred, or
- An absent/unmarried parent has not been previously referred.
When a child was born prior to 1997 and the parents were unmarried at the time of conception (this applies to paternity referrals only).

Important: Child support enforcement does not apply to recipients who receive Medi-Cal Only. However, the EW must advise Medi-Cal Only recipients that child support services are available, but not mandatory. The CW 2.1Q provides a box that the recipient must check, indicating whether or not additional child support services are requested. This information must be entered into the Do you want other child support enforcement services? field under the Support Enforcement Services (Medi-Cal Only) section of the Absent Parents page.