Restricted-scope Benefits

Note: Effective 1/1/2024 SB 184 amended the California Welfare and Institutions Code (WIC) to expand eligibility for full-scope Medi-Cal to individuals of any age who do not have satisfactory immigration status (SIS), if otherwise eligible for Medi-Cal. The following policies still apply to any eligibility determinations before 1/1/2024.

Restricted-scope MC benefits are limited to emergency care and pregnancy-related services. Individuals can apply for and maintain restricted-scope MC year-round, even if a current emergency or pregnancy does not exist.

Non-citizens eligible to receive restricted-scope benefits include the following individuals:

A non-citizen with no documentation to prove SIS.
A non-citizen legally admitted to the U.S. for a limited period (i.e. temporary visa).
A U.S. citizen applicant/client who has not provided acceptable proof of citizenship/identity at the end of the reasonable opportunity period (ROP).

Eligibility

Individuals applying for restricted-scope MC must:

Be a California Resident, or have the intent to reside in CA.
Meet all other requirements for program eligibility.

SSN Requirement

Social Security numbers are not required for anyone who is only applying or eligible for restricted benefits.

If the client's SSN is known from other means, i.e., already on file, on MEDS, on earnings statements, etc., it must be used for IEVS and for any other MC related purpose.
Follow current pseudo number procedures if the SSN is unknown. [Refer to “Allowable Changes,” section 3.3.2]

Reminder: If an individual has an SSN and chooses to give this information or it is known from other means, the EW must record the SSN in SAWS. An IEVS applicant transaction is then generated.

Note: An SSN is not required for Victims of Human Trafficking and Serious Crimes to receive MC benefits. Refer to TCVAP.

Emergency Care

The medical provider, not the EW, determines if the medical service is an “emergency”. The emergency must be certified by a physician or other appropriate medical provider. DHCS may review the provider's decision that an emergency existed and that certain follow-up treatment services were medically justified.

A medical emergency is generally defined as “a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, which in the absence of immediate medical attention could reasonably be expected to result in any of the following:

Placing the patient's health at risk,
Serious damage to bodily functions, or
Serious harm to any bodily organ or part.”

Pregnancy Services

Pregnancy-related services include prenatal care, labor and delivery, 60-day postpartum services, and family planning services which may continue after the sixty-day postpartum period.

Undocumented Non-citizens and Visas

Undocumented non-citizens and non-citizens with unexpired temporary visas (students or visitors) may qualify for restricted benefits if they:

Are otherwise linked and eligible for MC, and
Also meet California residency requirements.

Example Example A single adult undocumented non-citizen, age 40, applies for MC. He claims to be disabled, has income less than 138% FPL and meets all other MC eligibility requirements, including intent to remain in California. A DDSD packet is completed; and he is approved on a restricted-scope MAGI MC aid code.

Reminder: Undocumented non-citizens age 26 years of age or older are not entitled to full scope MC unless they are eligible under PRUCOL and they are claiming to have SIS.

Undeclared Status

Any person who does not wish to declare or verify citizenship, immigration status, social security number or birthplace may only receive restricted-scope benefits.