In 2015, California expanded Medi-Cal to all low-income California children younger than 19, regardless of immigration status, through Senate Bill 75 (SB 75). The expansion is set to take effect in May 2016.
Eligibility and Enrollment Details About the Expansion
- SB 75 provides individuals under age 19 who do not have satisfactory immigration status or are unable to establish satisfactory immigration status full-scope Medi-Cal benefits, no sooner than May 1, 2016.
- SB 4 amended SB 75 to ensure that children currently enrolled in restricted-scope Medi-Cal will transfer to full-scope Medi-Cal without having to reapply.
- Income eligibility is 266 percent of the federal poverty level, which is $5,387 per month or $64,638 annually for a family of four. See the chart at the end of ACWDL 16-03 for DHCS’s 2016 FPL levels.
- Children with county-based coverage or who are enrolled in Kaiser Child Health Plan must apply for Medi-Cal, if they are not already enrolled in restricted-scope Medi-Cal.
- The same rules apply to SB 75 children as apply to all other Med-Cal children (choice of health plan, premiums, California Children’s Services (CCS)).
- Note: A child currently enrolled in CCS will continue to receive services for CCS-eligible conditions through CCS providers.
- Full-scope services that are otherwise not available to those with restricted-scope coverage include: dental, vision, preventive services (immunizations, well-child check ups), prescriptions, and ongoing primary/specialty care. General list of services covered by Medi-Cal is in #3 in this FAQ.
- General DHCS FAQ on SB 75 Implementation
- Transition Population: Individuals under the age of 19 who are currently enrolled in restricted-scope Medi-Cal.
- New Enrollee Population: Individuals under the age of 19 who meet all eligibility requirements for SB 75 but are not enrolled in the Medi-Cal program at the implementation of SB 75. These individuals will need to apply for Medi-Cal through the current application process. This includes children:
- Currently enrolled in Kaiser’s Child Health Program.
- Currently enrolled in a local county health plan.
- Not enrolled in any health coverage.
Important Dates (e.g., progress, notices, start dates)
- April 15, 2016 – DHCS sent out the first notice to those who are currently enrolled in restricted-scope Medi-Cal. The notice includes information about the SB 75 expansion and frequently asked questions.
- May 16, 2016 – This is the date that DHCS has scheduled to complete and implement system changes to allow undocumented children to be enrolled into full-scope Medi-Cal.
- Note: This start date is based on whether the enrollment system updates remain on schedule and may change if more time is needed to address systems issues.
- Additional notices will be sent to families:
- Second Notice (at transition): Notice of Action (NOA) that tells beneficiary they have been changed from restricted-scope to full-scope Medi-Cal coverage.
- Third Notice (after transition): Medi-Cal managed care health plan enrollment information and instructions.
- Health Plan Choice Packet (close to third notice): Health Care Options “choice packet” advising beneficiaries to choose their plans and providers.
- Coverage for Medi-Cal begins on the first day of the month in which the expansion begins.
- While the coverage expansion begins on May 16, 2016 families can be paid back for care received May 1, 2016 and after.
- If a family paid out of pocket for an enrolled child’s services provided in May, the family can submit a claim to Medi-Cal to get reimbursed. Providers can also submit claims for any eligible full-scope services provided in May.
- Families can also request retroactive benefits up to the three months prior to the application month. In order to receive approval for retroactive months, applicants will need to be eligible for the requested months. Because eligibility for undocumented children begins in May, this will primarily apply to other citizen or legally residing family members who are also newly enrolled in Medi-Cal at the time that an undocumented child family member is enrolled. If undocumented children are enrolled after the May start date, they would then be eligible to apply for retroactive coverage.
- DHCS policy on getting retroactive coverage.
- MC 210A is the form to get retroactive coverage. However, currently, it needs to be simplified and updated since folks in MAGI Medi-Cal shouldn’t have to answer the questions about bank accounts and property.
- Western Center on Law and Poverty’s guide on page 5.211 has more information on retroactive Medi-Cal coverage.
See Information for Families to Know in Preparing to Apply and How to Apply for Medi-Cal for more enrollment information.