Deemed Eligibility for Infants

Infants born to individuals who are eligible for and receiving MC on the date of the infant’s birth are automatically deemed eligible for MC for one year:

Without a separate MC application, and
Without requiring a Social Security Number (SSN) for the infant, and
Without considering the infant’s living arrangements or the mother’s eligibility status.

A new application is required when the child turns age one only in those cases when the mother is ineligible and no one else in the family is receiving MC.

Program Eligibility

Under DE, the infant’s eligibility is determined based on the household (tax household or MFBU) circumstances in the birth month and remains the same until the infant’s first birthday unless the change in circumstance is beneficial to the infant (i.e. lower SOC).

If the mother is receiving MC under the Supplemental Security Income/State Supplementary Payment (SSI/SSP) program, the Federal Breast and Cervical Cancer Treatment Program (BCCTP), or the Medi-Cal Inmate Eligibility Program (MCIEP), there will not be an open MC case in CalSAWS. A new MC case will need to be established if there is no previous case history. The annual RD is due when the infant turns age one. If there are other family members on MC, or the infant’s father is now requesting MC, the infant is included in the same MFBU/tax household for regular MC eligibility.

Residency

California residency is a federal requirement to receive MC. As long as the infant resides in California, the infant meets the residency requirement for DE.

DE does not continue when an infant moves from the state of birth where he/she initially received DE to another state. When a DE infant moves to another state, the DE terminates. Likewise, when an infant with DE arrives from another state, he/she is not DE eligible because the infant’s mother was not eligible for and receiving MC in California on the date of birth.

Deficit Reduction Act (DRA) of 2005

DE infants are exempt from DRA citizenship and identity requirements. Children born in the U.S. to an individual who is eligible for and receiving MC on the infant’s date of birth are deemed to have provided satisfactory documentation of citizenship and identity and are not required to provide any additional documents.

Infants Born to Minor Consent Mothers

Infants born to mothers receiving limited scope pregnancy related services under the Minor Consent Program qualify for DE.

Reminder: Establish the case for the newborn using a separate case number from the Minor Consent case.

Infant Born to Youths Receiving Adoption Assistance Program (AAP) Benefits

Under the AAP program MC is automatically included as a part of the benefits. Infants born to mothers who are receiving AAP are eligible for MC under the DE for Infants program.

When the Foster Care (FC) bureau is notified that a youth receiving AAP benefits has had a baby the FC bureau must open a new case only for the infant and the infant’s mother.

FC Clerical is only required to complete the Application Registration then forward the case number and the application for MC Expedited Enrollment to District Office. The infant cannot be added to an existing AAP case. Once the case is approved in District Office it follows current MC policy.

The following process must be followed when an infant is born to a mother receiving AAP benefits:

Infant Born to AAP Youth

FC Clerical/FC EW
1. Receives notification the AAP youth has had a baby.
FC EW
1. Reviews the application/request forwards to FC Clerical for Application Registration for MC only.
FC Clerical
1. Completes the Application Registration for MC with only the Infant and the Infant’s mother and forwards the following information to District Office:
  1. SCD 1374 FC,
  2. When available, the Application,
  3. A copy of the CalSAWS -Initial Assignment screen, and
  4. Any additional information provided by the adoption social worker, adoptive parents, and/or the youth receiving AAP benefits.
District Office
1. Receives the Application and approves MC.
  1. Note: The infant’s redetermination of benefits has no effect on the open AAP case.

This process only applies to DE infants that are initiated at the FC Bureau

Retroactive Eligibility

An infant can receive DE retroactively when one of the three months prior to the application month is the infant’s birth month and the mother, parent, legal guardian or responsible relative of the infant requests MC coverage for that month. If the infant’s mother had MC eligibility in the birth month, then apply DE to the infant beginning in that retroactive month.

ExampleExample

A mother applies for MC on July 6, 2017 for herself and her infant. The infant’s date of birth was June 16, 2011. The mother indicates on her application that she has unpaid medical bills for May and June and requests Medi-Cal for May and June. The EW approves MC for July 2017 and ongoing. In determining her retroactive Medi-Cal eligibility, the EW determined that she was not eligible in May but eligible for June. Because the infant’s month of birth is in the retro month of June and the mother was MC eligible in June, the infant has DE beginning in June.

Infant's SOC

The infant’s SOC will remain, through the month that the child reaches age one, the same as his/her SOC during the month of birth.

If the mother has no SOC MC on the date of the infant’s birth, the infant has DE with no SOC, regardless if the mother has full scope or restricted benefits.

Important: A mother who is concurrently eligible for the Income Disregard program and MC with a SOC does not have to meet the SOC for her infant to be DE. Enrollment by the mother in the Income Disregard program entitles the infant to DE if the infant is otherwise eligible.

Example 1: Mother eligible for no SOC Restricted BenefitsExample 1: Mother eligible for no SOC Restricted Benefits

Mother is eligible only for no SOC pregnancy-related MC with restricted benefits in the month of July 2017 and gives birth to an infant on July 17, 2017. Because the mother was MC eligible on July 17th, the infant has DE with no SOC until the end of the month in which the infant reaches age one.

Example 2: Mother Eligible for no SOC Medi-CalExample 2: Mother Eligible for no SOC Medi-Cal

A mother receiving no SOC Medi-Cal in the month of May 2017 gives birth to an infant on May 31, 2017. In July, the mother becomes ineligible for MC and her MC is discontinued. Because the mother had no SOC Medi-Cal on the day of the infant’s birth, the infant continues with no SOC Medi-Cal under DE until the end of the month in which the infant reaches age one.
If the mother has eligibility for Medi-Cal with a SOC in the birth month and meets her SOC in the birth month, the infant has DE with the same SOC as the mother. In accordance with federal guidelines, an individual with a SOC is ineligible for MC until the individual pays or obligates to pay his/her SOC. Therefore, unless the mother paid or obligated to pay her SOC in the birth month, the mother is not Medi-Cal eligible in that month and the infant would not have DE for MC. The EW will need to verify the SOC obligation in MEDS prior to approving DE for an infant.

Example 3: Mother’s SOC Unmet in the Birth MonthExample 3: Mother’s SOC Unmet in the Birth Month

A pregnant woman has employer covered medical insurance. Her medical insurance has a high co-payment and does not cover some medical expenses for labor and delivery so she applies for MC. The EW determines she is only eligible for MC with a $700 SOC. She delivers her infant and pays her employer insurance copayment of $550. She does not meet or obligate to meet the remaining $150 of her $700 SOC in the birth month. Because she still has $150 of her unmet SOC, the mother does not receive MC on the date of the infant’s birth. Therefore, the infant is not entitled to DE.

Important: A mother currently eligible for restricted benefits under the Income Disregard Program and full-scope Medi-Cal with a SOC does not have to meet the SOC for her infant to have DE. Enrollment in the Income Disregard Program entitles the infant to DE as long as the infant is otherwise eligible for deeming.

Example 4: Mother’s SOC Met in the Birth MonthExample 4: Mother’s SOC Met in the Birth Month

In February 2017, a pregnant individual applies for MC and is eligible with a $350 SOC beginning February 2017. The individual delivers in July and meets the $350 SOC for the birth month of July. Because the mother met or obligated to meet the $350 SOC in the birth month, she is certified as meeting her SOC and therefore Medi-Cal eligible. The infant has the same SOC as the mother and has DE until the end of the month in which the infant reaches age one.

Note: There will be instances during an infant’s DE period that the mother’s SOC is reduced. When the mother has a lower SOC, the infant will also have a lower SOC.

Example 5: Mother’s SOC ReducedExample 5: Mother’s SOC Reduced

A pregnant individual has eligibility for SOC MC beginning February 2017 and ending January 2018. The woman delivers her baby in July and meets her SOC in that month. Her infant has DE with the same SOC amount as the mother until the end of the month in which the infant reaches age one. In August the mother’s company furloughs its employees and the mother has a cut in pay. The mother’s income goes down and she now has a lower SOC. The infant’s SOC will also be lowered. If the mother’s income continues to go down prior to the infant reaching age one, the infant’s SOC will also continue to go down. If the mother’s SOC decreases to zero, the infant will have zero SOC until the end of the month in which the infant reaches age one, even if the mother’s income increases again and she goes from no SOC to SOC prior to the infant reaching age one because CE protects the DE infant.

Example 6: Mother Met Her SOC in the Birth Month, Change in MFBUExample 6: Mother Met Her SOC in the Birth Month, Change in MFBU

A pregnant woman and her 18-year old child have MC eligibility with a SOC beginning February 2017 and ending January 2018. The pregnant woman delivers in July and meets her SOC in that month. The infant has DE with a SOC until the end of the month in which the infant reaches age one. However, the 18-year old member of the MFBU moves out of the household the following month. The MFBU and the maintenance need level decrease but the income of the MFBU does not change. This change results in a higher SOC. The infant’s SOC also increased because the CE program only disregards increases in income, not the change in MFBU composition or Maintenance Need Level.

Increased Income, Infants (MN/MI Programs)

For Non-MAGI, use this chart to determine under which program an infant's eligibility continues through the month that the child turns age one, when there is an increase in family income or SOC:

Increased Income, Infants

If the Prior Month Aid is...	And Income Increases...	Then Continue Eligibility for the Infant under....
No SOC, MN/MI or PA	But does not exceed Maintenance Need	MN/MI, no SOC. (Unaffected by CE)
	Between Maintenance Need and 200% of FPL	Income Disregard Program. No SOC.
	Over 200%	Income Disregard Program. No SOC.
Income Disregard Program (between Maintenance Need and 200% FPL)	At or Below 200%	Income Disregard Program. No SOC.
	Over 200%	Income Disregard Program. No SOC.
Property Waiver Provision	At or Below 200%	Property Waiver Provision. No SOC.
Property Waiver Provision	Over 200%	Property Waiver Provision. No SOC. (Use Income Disregard Program Aid Code.)
SOC, MN/MI (Income over 200%)	Still Over 200%	Continue infant at prior month's SOC.

For infants on MAGI, an increase in tax household income over the limit for MAGI should trigger Soft Pause. Due to system limitations, the infant must remain on Soft Pause until the end of the DE period or when other changes (i.e. tax household information) make the infant ineligible.

Unmarried Fathers - MN/MI (Non-MAGI) MC

MFBU

An unmarried father living in the home is not required to be in the MN/MI MFBU until the month following the month that his child turns age one, unless he is requesting MC for himself and/or any of his separate or mutual children. The unmarried father must be added to the MFBU the first of the month after the infant turns one year old.

Income/Property

Increases in the income or property of an unmarried father do not affect the infant until the child reaches age one, regardless of whether the unmarried father wants MC himself or other children.

EWs are not required to verify the income or resources of an unmarried father (who does not want MC for himself or other children) until the infant turns age one.

Information Provided

Although an unmarried father is not required to be in the MN/MI MFBU until the newborn reaches age one, occasionally he may provide all necessary information and verifications. When this occurs:

He may be included in the MFBU.
If adding him adversely affects the mother or child (results in excess property or a SOC) then Sneede rules apply.

Sneede

In cases where there is an unmarried father in the home and the MFBU has a SOC or excess property, the following rules apply when determining eligibility for the newborn:

After the baby is born, the child's eligibility is tied to the mother.
If the unmarried father wants MC for himself or for his other mutual children and there is a SOC or excess property, Sneede rules apply.

Include the newborn under age one in the Responsible Relative determination, even though the newborn will not actually receive an allocation from the unmarried father until the month after the child turns age one.
There is to be no allocation from the unmarried father to the infant during CE.
Mother's income, before any increases, is allocated to the baby.
If a pregnant individual/infant are included in a Mini Budget Unit (MBU) that has a SOC, evaluate them under the poverty level programs.
If a SOC remains and they had no SOC or a lower SOC in the prior month, apply CE rules.

Medical Support Enforcement

For purposes of medical support enforcement, an absent parent still has a legal responsibility for the health and welfare of his child(ren). A medical support referral must be made at the end of the mother’s 365-day postpartum period if there is an absent parent.

General Newborn Referrals

The “Newborn Referral Form” (MC 330) was developed by the Department of Health Care Services to facilitate the enrollment of DE newborns into MC. The MC 330 is received from various agencies and hospitals throughout Santa Clara County. Once a referral is received designated staff will review the information provided to determine the correct course of action.

Forwarding Referral

If the Mother...	Then the Referral Will Be...
Is active in another county,	Forwarded to the county of record by designated staff.
Is active on MC in Santa Clara County,	Forwarded to the appropriate District Office for assignment. Use the information provided to activate the infant on the mother’s Medi-Cal case.
Is receiving SSI/SSP, BCCTP, or MCIEP Medi-Cal benefits at the time of birth,	Processed as an application if no other family members are receiving Medi-Cal.
Has no active case record,	Held for 30 days, then file-cleared again in CalSAWS/MEDS. If the case is found to be active or pending at that time, the referral will be forwarded to the appropriate office for task assignment. If no case is found to be active at that time, a “Medi-Cal Notice of Newborn Referral” (SCD 1374) must be completed and sent to the parent by the designated staff. If the child has an active Accelerated Enrollment (AE) or CHDP Gateway MEDS record, the referral will be forwarded to AAC for processing. Reminder: Staff must enter the date of application recorded on the MEDS INQP screen.

Medi-Cal Notice of Newborn Referral Form (SCD 1374)

The “Medi-Cal Notice of Newborn Referral” (SCD 1374) must be completed and sent to the parent/caretaker relative by designated clerical staff when no active record is found after 30 days. As part of Santa Clara County’s MC outreach effort, the notice explains to the new mother that she may apply for MC if she wishes.

The SCD 1374 informs the parent that the county has no MC case record and he/she must contact the Social Services Agency to apply for MC.

Infants born to mothers receiving SSI/SSP, BCCTP or MCIEP at the time of birth are also deemed eligible. The MC case must be established by using the information available on the referral and the mother’s MEDS record.

Note: General newborn referrals do not have a 5 day due date and are not received via the Health and Hospital System as are the Baby Gateway Referrals.

Baby Gateway Referrals

The Baby Gateway program was implemented to expand health coverage to infants, secure a medical home, reduce emergency department use for infants, and ensure parents are given the appropriate resources to create a safe and healthy environment for their children. The program is a partnership between Santa Clara County Social Services Agency (SSA) and the Santa Clara County Health and Hospital System (HHS).

The Baby Gateway program applies ONLY to O’Connor Hospital, Saint Louise Regional Hospital, and Santa Clara Valley Medical Center.

Baby Gateway Referral Procedure

Following the birth of a child, Certified Application Assistors (CAAs) working within the participating hospitals listed above, will meet with the MC eligible mothers before they leave the hospital. As part of the visit with each newborn’s mother, the CAA will assist the mother with:

Providing the required information to Health and Hospital System to add the newborn to the active MC case,
Selecting a health plan and a primary care physician, and
Scheduling the six week well baby appointment with a pediatrician.

Note: Newborn referrals sent to SSA by individuals and agencies outside of the Baby Gateway program do not qualify as Baby Gateway referrals and should follow normal processing procedures.

HHS will gather the newborn requests from each hospital and combine information onto a single spreadsheet to send to SSA. Designated SSA staff will:

Receive the spreadsheet via email from Health and Hospital System.
Maintain a record of all Baby Gateway referrals received, including:
- Date the Referral is Received
- Mother’s name
- Mother’s CIN
- CalSAWS Case #
- Child’s Name
- Child’s Date of Birth
- Child’s Gender

Note: The MC 330 is no longer sent for Baby Gateway Referrals.

Forwarding Referrals

Baby Gateway referrals are forwarded as outlined in the table below.

Forwarding Baby Gateway Referrals

If...	Then...
An active MC case exists AND the newborn is unknown,	Send the list of eligible names to clerical staff for Task creation. Note: If a Task was previously created and it has been more than 5 days and the child is still not active on MC send the spreadsheet to the appropriate office’s Management Analyst for follow up with the assigned EW supervisor.
An active MC case exists AND the newborn is known to CalSAWS and active on MC,	Return the CIN to Health and Hospital System.
No MC case exists for the mother,	Return a “no match” response to Health and Hospital System.

Baby Gateway Workflow

Baby Gateway Work Flow

Patient/ Mother
1. Provides CAA with required information to add the newborn to the MC case.
CAA
1. Obtains a list of all MC Active mothers from the hospital.
2. Visits the client in the hospital.
3. If the list is not available or the patient is not on the list,
  1. Emails the SCD 115 to the Baby Gateway email at SSA.
  2. Calls the OS III at SSA to verify MC status.
  3. The OS III researches in CalSAWS and MEDS to verify the client’s MC status. If the client is:
    1. Active on MC:
      1. Proceeds with requesting the necessary information and updating the Baby Gateway spreadsheet.
      2. Sends referrals to HHS.
    2. Not active on MC:
      1. Assists the client in completing the MC application via BenefitsCal and obtaining the appropriate verifications for the family unit.
      2. Note: This application will follow regular BenefitsCal process.
Health and Hospital Sytem
1. Collects the newborn referral information from the participating hospitals.
2. Combines all information onto one spread sheet.
3. Emails the Baby Gateway spreadsheet to designated SSA Staff once a week.
Designated SSA Staff
1. Once a week, receives the spreadsheet from Health and Hospital System.
2. Performs data match to identify:
  1. Child’s CIN
  2. Child’s aid code
  3. Approval Date
  4. Known or Unknown to CalSAWS
3. Sends the disposition of the referrals on a weekly basis to designated Health and Hospital staff member.
4. Sends unknown Baby Gateway newborn information to designated SSA Clerical staff.
5. Sends referrals over 5 days, where the child is still unknown, to the appropriate district office Management Analyst.
Designated Clerical Staff
1. IDs the mother’s active MC case.
  1. Note: Per policy refer cases with Foster Care and the Adoption Assistance Program to the Foster Care Bureau via FosterCareProcessing@ssa.sccgov.org
2. Creates a Task with Category: Case Update and Type: Baby Gateway with Priority: High for each newborn referral to assign the add-a-person task to the assigned EW or Unit.
  1. Note: The Foster Care Bureau will create the Foster Care Task. Refer to Foster Care Handbook.
EW
1. Receives the High priority Task.
2. Within 5 working days of receiving the Task, adds the newborn to the MC case, per established business process.
3. If the child's tax filing information is unavailable.
  1. Note: Request the information from the mother. Do not delay benefits for the child, if unavailable, enter the child as a non-filer.
EW Supervisor
1. Monitor all Baby Gateway assignments to ensure a 5 business day turn around for add-a-person. If the baby is not added within 5 business days of assignment, communicate with the worker to expedite the process.

Expedited Enrollment

MC eligibility for infants may be established through receipt of:

A Newborn Referral Form (MC 330)
Telephone Call
Letter,
Fax, or
Other Contact.

The information provided must include sufficient information to link the infant to the mother’s MEDS record or an open MC case.

The minimum basic information required for the mother is the Benefits Identification Card (BIC) or SSN. The required information for the infant is the name, gender and date of birth.

EWs are not to request the following items to add the DE infant:

Birth Certificate
Social Security Number
Income documentation
Immigration Status Form (MC 13), or
“Medical Support Questionnaire” (CW 2.1/CW 2.1Q).

Note: A medical support referral must be made on the infant once the mother’s 365- day postpartum period has ended if there is an absent parent.

If the information in CalSAWS/MEDS indicates the mother’s case is closed, the infant’s MC must be approved effective the month of birth through the current month as long as the mother was MC eligible at the time of birth.

Note: A DE infant who is no longer a California resident must be discontinued. A ten day notice of action (NOA) is not required.

Change in County of Residence

A change in county of residence within California does not affect the infant’s DE. When an ICT is received, the EW must review the information in the case file from the Sending County and continue the infant’s DE. If there are changes to the family’s circumstances that may affect the DE infant, the Receiving County will review and make the necessary changes.

Resetting RD when Family Members are Discontinued

When a negative action is taken on a case with a deemed infant, the infant must retain the same level of benefits until their first birthday. When the rest of the household is discontinued, the RD must be updated to the infant’s first birthday so the infant’s eligibility can be reevaluated once he/she is no longer deemed.

Discontinued Family Reapplies During SB 87 Process

If during the SB 87 process for the DE infant, or at any time prior to the end of the infant’s DE period, any discontinued family members wish to reapply for MC, a new application must be completed to obtain information to determine the family’s eligibility. However, do not delay the infant’s eligibility determination if information is available for the infant to continue MC under another program. Instead, grant the infant’s eligibility without regard to the pending application of the other family member(s). When the family’s new eligibility is determined, add the infant in the family’s case as an eligible MFBU member with the same RD date of the family.

Rescind DE Due to Whereabouts Unknown

When a family with a DE infant is discontinued for whereabouts unknown and later the family reestablishes contact, reinstate DE for the infant, for any months discontinued due to whereabouts unknown, unless the family lost California residency.