§ 2699.6600. Application.
10 CA ADC § 2699.6600Barclays Official California Code of Regulations
10 CCR § 2699.6600
§ 2699.6600. Application.
(4) The program application, entitled “Family Health Coverage Mail-In Application, for Medi-Cal and Healthy Families” (MC321 HFP, 4/06), is hereby incorporated by reference. Alternatively, the program shall utilize the on-line application submitted electronically via the internet and the school lunch application and any supplemental forms received pursuant to Section 14005.41 of the Welfare and Institutions Code to make an eligibility determination.
(b) The applicant shall sign and date the following declaration: I declare under penalty of perjury under the laws of the State of California that the answers I have given in this Application and the documents given are correct and true to the best of my knowledge and belief. I declare that I have read and understand the Application Instructions, the declarations, and all information printed on this Application.
(E) An indication of whether the applicant is over the age of 18 years and applying on behalf of a child or children, and/or on behalf of a child-linked adult. An indication of whether the applicant is an 18 year old applying on his or her own behalf; the applicant is an emancipated minor applying on his or her own behalf; the applicant is a minor who is not living in the home of a parent, legal guardian, caretaker relative, foster parent, or stepparent and is applying on his or her own behalf; or the applicant is a minor who is applying on behalf of his or her child.
1. If the applicant is a parent or stepparent, an 18 year old applying on their own behalf, a child-linked adult applying on his or her own behalf or that of another child-linked adult or a minor applying on his or her own behalf or on behalf of his or her child, for the household of each person applied for, the first, middle initial, last name, gender and date of birth of all family members living in the household, each person's relationship to the person applied for and their monthly income.
3. If the person for whom application is being made is a qualified alien with an affidavit of support pursuant to section 213A of the Immigration and Naturalization Act, the calculation of household income must include the sponsor's income as set forth in Section 421 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), unless the person is eligible pursuant to Insurance Code Section 12693.76.
(K) Documentation of the total monthly gross household income for either the previous or current calendar year. For each person listed pursuant to subsections (F) and (H) above, provide social security number (optional) and documentation for each source of income. Such documentation shall be provided for the previous or current year as indicated below:
a. Federal tax return. If self-employed, a schedule C must be included. If a person with reported income on the federal tax return is a step-parent, the step-parent's W-2 form is required to determine the amount of income associated with the financially responsible parent of the child being applied for.
b. All of the following that are applicable and that reflect the current benefit amount: copies of award letters, checks, bank statements, passbooks, or internal revenue service (IRS) 1099 forms showing the amount of Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability workers' compensation, unemployment benefits, child support, alimony spousal support, pensions and retirement benefits, loans to meet personal needs, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings, dividends, or interest income.
e. All of the following that are applicable and that reflect the current benefit amount: copies of award letters, checks, bank statements, or passbooks showing the amount of Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability workers' compensation, unemployment benefits, child support, alimony, spousal support, pensions and retirement benefits, loans to meet personal needs, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings, dividends, or interest income for the previous month.
3. If documentation pursuant to 1. or 2. cannot be provided, an affidavit of income written by hand by the recipient of the income. If the individual who receives the income is unable to write the affidavit by hand because of physical or literacy limitations, the individual will sign an affidavit written on his or her behalf with a mark (unless physically incapable) and include the printed name and signature of a witness. The affidavit of income shall include the following:
(L) The name of each family member living in the home who pays court ordered child support, court ordered alimony, or health insurance and the monthly amount paid. The name and age of each person for whom payments are made for child care and/or disabled dependent care by a family member living in the home and the monthly amount paid. Documentation of court ordered child support and/or alimony paid, health insurance paid, and child care and/or disabled dependent care expenses paid. Documentation includes copies of court orders, cancelled checks, receipts, statements from the District Attorney's Family Support Division or other equivalent document.
(T) For each declaration made pursuant to (S), documentation of the individual's status. If documentation is unavailable at the time of application, persons declaring a status listed under subsection (S) above may submit documentation within two months from the date of enrollment. If any person for whom application is being made was previously disenrolled pursuant to Section 2699.6611(a)(3), documentation for that person shall be submitted with the application.
(U) A declaration that each person for whom application is being made is not eligible for any California Public Employees Retirement System Health Benefits Program(s) or is eligible for a California Public Employees Retirement Health Benefits Program but the employer contribution for dependent(s) is less than $10.
a. i. In any geographic region or portion thereof, the program may designate one or more participating dental plans with the lowest per-subscriber costs to the program. For purposes of this section, “designated dental plan” means a participating dental plan that the program has designated in accordance with this section.
iii. At least one subscriber in the household currently is enrolled in a participating dental plan that is not a designated dental plan. This exception shall apply even if (A) the subscribers move to an area where there is a designated dental plan; (B) the program makes a designated dental plan available in the area where the subscribers reside; or (C) the applicant must make a new choice of dental plan because the dental plan in which the subscribers were enrolled no longer is available.
(EE) If applicable, the applicant's signed authorization that the program may release information over the telephone about the application status of the individual(s) applied for by the applicant to a representative of the enrollment entity designated by the applicant on the application. This permission will end on the date the program mails the results of the eligibility determination on this application.
(FF) If the applicant received assistance from a certified application assistant, the applicant's signed authorization (if applicable) that the program may release information notifying the entity with whom the certified application assistant is affiliated of the applicant's Annual Eligibility Review date.
(GG) If an applicant or the person for whom application is being made is American Indian or Alaska Native, acceptable documentation must be submitted to exempt the applicant from family contribution payments and benefit copayments. The exemption from family contributions and benefit copayments shall occur after receipt of such documentation. Notwithstanding the previous sentence, the exemption from family contributions will begin on the date of enrollment and continue for two months pending the receipt of acceptable documentation. If acceptable documentation is not received at the end of the two month exemption period, the appropriate family contribution will be assessed pursuant to Subsection 2699.6813(a). The applicant must indicate on the application that he or she is requesting a waiver of the family contributions. Acceptable documentation for the applicant or the child includes:
Credits
Note: Authority cited: Sections 12693.21, 12693.22, 12693.75 and 12693.755, Insurance Code; and Section 14005.41, Welfare and Institutions Code. Reference: Sections 12693.02, 12693.21, 12693.22, 12693.43, 12693.46, 12693.70, 12693.71, 12693.73, 12693.74, 12693.75 and 12693.755, Insurance Code.
History
1. New article 2 (sections 2699.6600-2699.6629) and section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment filed 12-14-98 as an emergency; operative 12-14-98 (Register 98, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-13-99 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 12-14-98 order transmitted to OAL 3-25-99 and filed 5-6-99 (Register 99, No. 19).
5. Amendment filed 5-26-99 as an emergency; operative 5-26-99 (Register 99, No. 22). A Certificate of Compliance must be transmitted to OAL by 9-23-99 or emergency language will be repealed by operation of law on the following day.
6. New subsection (c)(1)(EE) filed 8-5-99 as an emergency; operative 8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 5-26-99 order transmitted to OAL 9-17-99 and filed 10-28-99 (Register 99, No. 44).
8. Certificate of Compliance as to 8-5-99 order, including new text for subsection (c)(1)(J), transmitted to OAL 10-29-99 and filed 12-3-99 (Register 99, No. 49).
9. Amendment of section and Note filed 1-10-2000 as an emergency; operative 1-10-2000 (Register 2000, No. 2). A Certificate of Compliance must be transmitted to OAL by 5-9-2000 or emergency language will be repealed by operation of law on the following day.
10. Amendment of subsection (a) and new subsections (c)(1)(FF)-(c)(1)(FF)3. filed 3-21-2000 as an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 1-10-2000 order transmitted to OAL 5-5-2000 and filed 6-16-2000 (Register 2000, No. 24).
12. Certificate of Compliance as to 3-21-2000 order, including further amendment of subsections (c)(1)(FF)2.-3., transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No. 29).
13. Amendment of subsections (a) and (c)(AA)3. filed 9-5-2000; operative 9-5-2000 pursuant to Government Code 11343.4(d) (Register 2000, No. 36).
14. Amendment of section and Note filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 4-29-2002 order, including further amendment of subsections (c)(1)(N) and (c)(1)(EE), transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
16. Amendment of subsections (a)(3), (a)(4), (a)(5) and (c)(1)(Q), repealer of subsections (c)(1)(Z)4. and (c)(1)(BB) and subsection relettering filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
17. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).
18. Amendment filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.
19. Certificate of Compliance as to 7-1-2004 order, including amendment of subsection (c)(1)(S)(3)., transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
20. Amendment of subsection (a)(3) filed 6-30-2005 as an emergency; operative 6-30-2005 (Register 2005, No. 26). Pursuant to Insurance Code section 12693.43(h), a Certificate of Compliance must be transmitted to OAL by 12-27-2005 or emergency language will be repealed by operation of law on the following day.
21. Certificate of Compliance as to 6-30-2005 order transmitted to OAL 10-5-2005 and filed 11-16-2005 (Register 2005, No. 46).
22. Amendment of subsection (a)(6), new subsections (d)-(d)(4) and amendment of Note filed 2-9-2006 as an emergency; operative 2-9-2006 (Register 2006, No. 6). Pursuant to subsection (c) of section 12693.75 of the Insurance Code, the adoption of this regulatory action is deemed an emergency, exempt from review by the Office of Administrative Law, and shall remain in effect for not more than 180 days unless readopted.
23. Certificate of Compliance as to 2-9-2006 order transmitted to OAL 7-21-2006 and filed 8-29-2006 (Register 2006, No. 35).
24. Amendments to subsection (a) deemed an emergency and exempt from OAL review pursuant to Section 75 of Chapter 74, Statutes of 2006, filed 7-31-2007; operative 7-31-2007 (Register 2007, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-28-2008 or emergency language will be repealed by operation of law on the following day. Amendments of subsection (c)(1)(AA)(2) and (c)(1)(BB)(1) filed 7-31-2007 as an emergency; operative 7-31-2007 (Register 2007, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-28-2008 or emergency language will be repealed by operation of law on the following day.
25. Certificate of Compliance as to 7-31-2007 order, including amendment of subsection (a)(4) operative 4-11-2008, transmitted to OAL 1-28-2008 and filed 3-12-2008 (Register 2008, No. 11).
26. New subsections (c)(1)(BB)1.a.i.-(c)(1)(BB)1.b.iii and amendment of Note filed 10-29-2009; operative 11-1-2009 pursuant to Government Code section 11346.1(d) (Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL by 4-30-2010 or emergency action will be repealed by operation of law on the following day. This regulatory action is deemed to meet the emergency standard and is exempt from OAL review pursuant to Insurance Code section 12693.22.
27. Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010 and filed 6-9-2010 (Register 2010, No. 24).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 10, § 2699.6600, 10 CA ADC § 2699.6600
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