Cal. Code Regs. Tit. 22, § 53845 - Enrollment Criteria

(a) Enrollment in plans shall be mandatory for eligible beneficiaries who meet all of the following criteria:

(1) Are eligible to receive Medi-Cal services that are not limited in scope;

(2) Have been determined to have a share of cost equal to zero;

(3) Do not meet the criteria for exemption from plan enrollment, specified in section 53887;

(4) Have been determined by their county welfare department to be eligible for one of the following programs:

(A) The section 1931(b) Program, which consists of the services described in Welfare and Institutions Code section 14005.30, including persons whose Medi-Cal eligibility is based upon their receipt of benefits under the California Work Opportunity and Responsibility to Kids (CalWORKS) Program.

(B) The Medically Indigent program for children under age 21, as specified in section 50251(a).

(C) The Medically Needy Program for families and caretaker relatives, specified in sections 50203(a)(2) and (3).

(D) The Other Public Assistance Program as specified in section 50237.

(E) The Special Zero Share of Cost Program for infants, as specified in section 50262; for children of age one to age six, as specified in section 50262.5; and for children of age six to age nineteen, as specified in section 50262.6.

(F) The Transitional Medi-Cal Program as established in accordance with Section 1931 of the federal Social Security Act (Title 42, United States Code, section 1396 u-1) and described in Welfare and Institutions Code sections 14005.8 and 14005.81.

(b) Enrollment in a plan shall be voluntary for eligible beneficiaries who meet all of the following criteria:

(1) Are eligible to receive Medi-Cal services that are not limited in scope;

(2) Have been determined to have a share of cost equal to zero; and

(3) Have been determined by their county welfare department to be eligible for one of the following programs:

(A) The federal Supplemental Security Income for the Aged, Blind, and Disabled Program (Title 42, United States Code, section 1382 et seq.) or who are deemed by the county welfare department to be Supplemental Security Income recipients in accordance with section 4913 of the federal Balanced Budget Act of 1997.

(B) The Medically Indigent Program for pregnant women, as specified in section 50251(b)(3).

(C) Foster Care Program as described in Article 5 (commencing with section 11400) Chapter 2, Part 3, Division 9 of the Welfare and Institutions Code.

(D) Adoption Assistance Program as described in Chapter 2.1 (commencing with section 16115) Part 4, Division 9 of the Welfare and Institutions Code.

(E) The Medically Needy Program for aged, blind and disabled beneficiaries, specified in section 50203(a)(1).

(F) The receipt of health care services through an Indian Health Service facility as defined in section 55100(j).

(G) The In-Home Supportive Services program.

(c) Children receiving services under either the Foster Care or Adoptions Assistance Programs may be enrolled voluntarily if:

(1) The county Director of Social Services, or his or her delegated representative, determines that it is in the best interest of the child;

(2) The child's caretaker agrees to the enrollment; or

(3) The probation officer in the case of a foster child who is a ward of the court approves the enrollment.

(d) Where the department determines that it is feasible, and the conditions of subsection (c) are met, a child receiving services under the Foster Care or Adoptions Assistance Programs who physically resides in a designated region, but whose county of residence for the purpose of determining eligibility for the Medi-Cal program is part of another designated or nondesignated region, may be permitted to enroll in either of the two plans in the designated region in which the child physically resides.

(e) Beneficiaries enrolled in one of the following form of other health coverage shall not be enrolled in a Medi-Cal managed care plan:

(1) Medicare HMO,

(2) CHAMPUS Prime HMO,

(3) Kaiser HMO or

(4) Any other HMO or prepaid health plan in which the enrollee is limited to a prescribed panel of providers for comprehensive services.

(f) Beneficiaries with other coverage in an HMO, as specified in (e)(1), (3) or (4) above, may be enrolled in the Medi-Cal plan, as specified in section 53889, if:

(1) The Medi-Cal plan in which the eligible beneficiary is enrolling is the same as the HMO in which the beneficiary is enrolled, and

(2) Such enrollment is allowed in the contract between the plan and the department.

Notes

Cal. Code Regs. Tit. 22, § 53845

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of section and NOTE filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).
4. Amendment of subsections (a)(4)(D), (a)(4)(F) and (b)(3)(G) and amendment of NOTE filed 7-21-2011; operative 8-20-2011 (Register 2011, No. 29).

Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14087.3 and 14087.4, Welfare and Institutions Code.

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of section and Note filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).
4. Amendment of subsections (a)(4)(D), (a)(4)(F) and (b)(3)(G) and amendment of Note filed 7-21-2011; operative 8-20-2011 (Register 2011, No. 29).