Section 2699.201 - Application(a) To apply for the program an individual shall submit:(1) The application described in subsection (d) of this subsection, or alternatively, the Single Streamlined Application as promulgated by the Department of Health Care Services and the California Health Benefit Exchange pursuant to Section 1413(b)(1)(B) of Public Law 111-148(42 U.S.C. 18083), together with all information, documentation, and declarations necessary to determine program eligibility as set forth in subsection (d) of this section; and(2) A cashier's check or money order for fifty dollars ($50.00), except that this pre-payment requirement shall not apply to applications received on or after January 1, 2014; and(3) A statement signed by the applicant agreeing that if the pregnant woman is enrolled, the applicant will pay the full subscriber contribution and acknowledging that the program will take aggressive action to collect the full subscriber contribution.(b) The applicant shall sign and date a declaration stating that the information is true and accurate to the best of his or her knowledge.(c) The applicant will be notified in writing that the application is incomplete and what documentation is required for completion.(d)(1) The application, entitled Access for Infants and Mothers (AIM) Application (rev 01.01.2014), which is incorporated by reference, shall contain the following: (A) The pregnant woman's full name,(B) The pregnant woman's current living address including house or building number (and unit number if applicable), street, city, county, state, and zip code, and phone number,(C) The pregnant woman's date of birth,(D) The pregnant woman's social security number (provision of the Social Security number is not mandatory),(E) The pregnant woman's ethnicity and primary language (not mandatory),(F) A declaration that the woman on whose behalf the application is filed is pregnant,(G) The expected delivery date of the pregnant woman's unborn child,(H) A declaration that the pregnant woman is not, to the best of the applicant's knowledge, beyond the 30th week of gestation in a current pregnancy, as of the application date,(I) Information about whether the applicant or anyone in the household smokes, but providing this information shall not be a condition of eligibility,(J) The address to which the bills for the subscriber's contribution are to be sent, if different from the current living address,(K) The first and last name, and date of birth of the baby's father if living with the pregnant woman,(L) Information about whether the father of the baby is married to the pregnant woman,(M) A list of all family members living in the home, their ages, and relationship to the pregnant woman,(N) A list of those family members living in the home who had income in the previous or current calendar year, and their social security numbers or individual taxpayer identification numbers, the amount of income and their tax filer or dependent status(provision of the social security number or individual taxpayer identification number is not mandatory but is necessary for electronic verification),(O) As necessary, documentation of the total monthly gross household income for either the previous or current calendar year. For each person listed in (N) above, provide documentation for each source of income. Such documentation shall be provided for the previous or current year as indicated below:1. For the previous calendar year:a. Federal tax return. If self-employed, a schedule C must be included.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, 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.2. For the current calendar year: a. A letter from the person's current employer. The letter shall be dated and written on the employer's letterhead, and shall include the following: ii. The employer's business name, business address and phone number.iii. A statement of the person's current gross monthly income for a period ending within 45 days of the date the program receives the document.iv. A statement that the information presented is true and correct to the best of the signer's knowledge.v. A signature by someone authorized to sign such letters by the employer. The signer shall include his or her position name or job title and shall not be the person whose income is being disclosed.b. Paystub or unemployment stub showing gross income for a period ending within 45 days of the date the program receives the document.c. If self-employed, a profit and loss statement for the most recent three (3) month period prior to the date the program receives the document. A profit and loss statement must include the following: ii. Name, address and telephone number of the business.iii. Gross income, gross expenses, and net profit itemized on a monthly basis.iv. A statement on the profit and loss, signed by the person who earned the income, which states, "the information provided is true and correct."d. A letter or Notice of Action from the County Welfare Office issued within the last two (2) months that includes: i. For each person for whom application is being made, a statement that the person is eligible for share-of-cost Medi-Cal,ii. A determination of total monthly household income and monthly household income after income deductions or a determination of MAGI, as applicable, pursuant to Section 2699.200(b)(C), and iii. A determination of the number of family members living in the household.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, 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.(P) The name of each family member living in the home who pays court ordered child support or court ordered alimony. 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. As necessary, documentation of alimony, student loan interest, 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.(Q) A declaration that the pregnant woman is not a beneficiary of either no-cost Medi-Cal or Part A and Part B of Medicare,(R) A declaration that the pregnant woman is a resident of the State of California,(S) A declaration that the applicant will abide by the rules of participation, utilization review process, and dispute resolution process of any participating health plan in which the pregnant woman is enrolled,(T) Information about any health coverage that is in effect for the pregnant woman, whether directly or through a spouse, the father of the child or otherwise, including, if requested, the name, address, and policy number of the current insurance or health plan,(U) A declaration that the pregnant woman is not, to the best of the applicant's knowledge, covered for maternity benefits in a private insurance arrangement. A pregnant woman with a separate, maternity only deductible or co-payment greater than $500 shall be deemed not covered for maternity benefits for purposes of this declaration,(V) Name of the primary employer of each adult family member who is employed,(X) A declaration that the applicant has reviewed the benefits offered by the participating health plans,(Y) A declaration that the applicant understands and will follow the rules and regulations of the program,(Z) A declaration that the applicant is giving permission for the program to verify family income, health insurance, residence, and other circumstances,(AA) A declaration that the subscriber is not being, and will not be, reimbursed by any health care provider or any state and local governmental entity for payment of the subscriber contribution and that no health care provider or state or local governmental entity is paying or will pay the subscriber contribution,(BB) An indication of the pregnant woman's choice of participating health plan, if there is more than one participating health plan,(CC) A declaration that the subscriber agrees to pay the required subscriber contribution, even if the subscriber does not take full advantage of the coverage or services.(DD) A declaration that the information and documentation submitted is true and correct to the best of the applicant's knowledge.(EE) Notwithstanding the provisions of subparagraphs (O) and (P) of this paragraph (1), for applications received on or after January 1, 2014, the applicant's attestation of income and deductions, subject to verification in a manner consistent with the verification provided for regarding the Single Streamlined Application as promulgated by the Department of Health Care Services and the California Health Benefit Exchange pursuant to Section 1413(b)(1)(B) of Public Law 111-148(42 U.S.C. 18083). 1. If the income and deductions cannot be verified electronically, as contemplated by subparagraph (EE), the application will be considered incomplete and will be processed as specified in Section 2699.200(b)(1)(A)1, 2 and 3.(2) The Social Security number and other personal information are needed for identification and administrative purposes.(3) A declaration that the applicant understands that if the pregnant woman is not found eligible for AIM, the application will be forwarded to the Medi-Cal Program in the county in which she resides for a determination of eligibility for no-cost Medi-Cal or to Covered California for a determination of eligibility for coverage by a Covered California plan, as applicable based on apparent income.Cal. Code Regs. Tit. 10, § 2699.201
1. New section filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-12-91 order transmitted to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Amendment of subsection (d)(1)(W) filed 6-8-92 as an emergency; operative 6-8-92 (Register 92, No. 24). A Certificate of Compliance must be transmitted to OAL 10-6-92 or emergency language will be repealed by operation of law on the following day.
4. Amendment of subsection (d)(1)(Q) filed 10-28-92 as an emergency; operative 10-28-92 (Register 92, No. 44). A Certificate of Compliance must be transmitted to OAL 3-1-93 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 6-8-92 order transmitted to OAL 9-24-92 and filed 11-5-92 (Register 92, No. 45).
6. Certificate of Compliance as to 10-28-92 order transmitted to OAL 2-9-93 and filed 3-24-93 (Register 93, No. 13).
7. Amendment of subsections (d)(1), (d)(1)(L) and (d)(1)(L)4 and new subsection (d)(1)(Y) filed 8-29-94 as an emergency; operative 9-1-94 (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-30-94 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 8-29-94 order, including amendment of subsection (d)(1)(L), transmitted to OAL 12-9-94 and filed 1-23-95 (Register 95, No. 4).
9. Amendment of subsections (a)(1)-(2) and (d)(1) filed 8-29-95 as an emergency; operative 8-29-95 (Register 95, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-27-95 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 8-29-95 order including amendment of (d)(1)(F) transmitted to OAL 12-11-95 and filed 1-22-96 (Register 96, No. 4).
11. Amendment of subsections (d)(1), (d)(1)(L) and (d)(1)(L)3. and new subsections (d)(1)(L)3.a-f. filed 8-9-96 as an emergency; operative 8-9-96 (Register 96, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-9-96 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 8-9-96 order, including amendment of subsection (d)(1)(k), transmitted to OAL 11-19-96 and filed 1-6-97 (Register 97, No. 2).
13. Amendment of subsections (d)-(d)(2) filed 3-17-2000 as an emergency; operative 3-17-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-17-2000 or emergency language will be repealed by operation of law on the following day.
14. Certificate of Compliance as to 3-17-2000 order, including further amendment of subsections (d)(1)(M)2.a.i.(iv). and (d)(1)(M)2.a.ii., transmitted to OAL 6-12-2000 and filed 7-10-2000 (Register 2000, No. 28).
15. Amendment filed 5-20-2003; operative 5-20-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 21).
16. Amendment of subsections (d)(1) and (d)(1)(M)-(N) 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.
17. Certificate of Compliance as to 7-1-2004 order, including further amendment of subsection (d)(1), transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
18. Amendment of subsection (d)(1), new subsections (d)(1)(K)-(L), subsection relettering and amendment of newly designated subsections (d)(1)(O) and (d)(1)(V) filed 8-14-2008; operative 8-14-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 33).
19. Amendment of subsections (d)(1) and (d)(1)(R) and amendment of NOTE filed 12-1-2009 as an emergency; operative 12-1-2009 (Register 2009, No. 49). A Certificate of Compliance must be transmitted to OAL by 6-1-2010 or emergency language will be repealed by operation of law on the following day.
20. Certificate of Compliance as to 12-1-2009 order transmitted to OAL 5-28-2010 and filed 7-1-2010 (Register 2010, No. 27).
21. Amendment filed 12-27-2013 as an emergency; operative 12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be transmitted to OAL by 6-25-2014 or emergency language will be repealed by operation of law on the following day. This filing is deemed an emergency and is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes of 2013, section 77.
22. Certificate of Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed 6-10-2014 (Register 2014, No. 24). Note: Authority cited: Section 12696.05, Insurance Code. Reference: Sections 12698(b), 12698(c) and 12698.05, Insurance Code; and Maternal and Child Health Access, Petitioner, vs. Managed Risk Medical Insurance Board (Superior Court of the State of California, City and County of San Francisco, Case No. CPF-08-508296).
1. New section filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-12-91 order transmitted to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Amendment of subsection (d)(1)(W) filed 6-8-92 as an emergency; operative 6-8-92 (Register 92, No. 24). A Certificate of Compliance must be transmitted to OAL 10-6-92 or emergency language will be repealed by operation of law on the following day.
4. Amendment of subsection (d)(1)(Q) filed 10-28-92 as an emergency; operative 10-28-92 (Register 92, No. 44). A Certificate of Compliance must be transmitted to OAL 3-1-93 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 6-8-92 order transmitted to OAL 9-24-92 and filed 11-5-92 (Register 92, No. 45).
6. Certificate of Compliance as to 10-28-92 order transmitted to OAL 2-9-93 and filed 3-24-93 (Register 93, No. 13).
7. Amendment of subsections (d)(1), (d)(1)(L) and (d)(1)(L)4 and new subsection (d)(1)(Y) filed 8-29-94 as an emergency; operative 9-1-94 (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-30-94 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 8-29-94 order, including amendment of subsection (d)(1)(L), transmitted to OAL 12-9-94 and filed 1-23-95 (Register 95, No. 4).
9. Amendment of subsections (a)(1)-(2) and (d)(1) filed 8-29-95 as an emergency; operative 8-29-95 (Register 95, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-27-95 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 8-29-95 order including amendment of (d)(1)(F) transmitted to OAL 12-11-95 and filed 1-22-96 (Register 96, No. 4).
11. Amendment of subsections (d)(1), (d)(1)(L) and (d)(1)(L)3. and new subsections (d)(1)(L)3.a-f. filed 8-9-96 as an emergency; operative 8-9-96 (Register 96, No. 32). A Certificate of Compliance must be transmitted to OAL by 12-9-96 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 8-9-96 order, including amendment of subsection (d)(1)(k), transmitted to OAL 11-19-96 and filed 1-6-97 (Register 97, No. 2).
13. Amendment of subsections (d)-(d)(2) filed 3-17-2000 as an emergency; operative 3-17-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-17-2000 or emergency language will be repealed by operation of law on the following day.
14. Certificate of Compliance as to 3-17-2000 order, including further amendment of subsections (d)(1)(M)2.a.i.(iv). and (d)(1)(M)2.a.ii., transmitted to OAL 6-12-2000 and filed 7-10-2000 (Register 2000, No. 28).
15. Amendment filed 5-20-2003; operative 5-20-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 21).
16. Amendment of subsections (d)(1) and (d)(1)(M)-(N) 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.
17. Certificate of Compliance as to 7-1-2004 order, including further amendment of subsection (d)(1), transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
18. Amendment of subsection (d)(1), new subsections (d)(1)(K)-(L), subsection relettering and amendment of newly designated subsections (d)(1)(O) and (d)(1)(V) filed 8-14-2008; operative 8-14-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 33).
19. Amendment of subsections (d)(1) and (d)(1)(R) and amendment of Note filed 12-1-2009 as an emergency; operative 12-1-2009 (Register 2009, No. 49). A Certificate of Compliance must be transmitted to OAL by 6-1-2010 or emergency language will be repealed by operation of law on the following day.
20. Certificate of Compliance as to 12-1-2009 order transmitted to OAL 5-28-2010 and filed 7-1-2010 (Register 2010, No. 27).
21. Amendment filed 12-27-2013 as an emergency; operative 12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be transmitted to OAL by 6-25-2014 or emergency language will be repealed by operation of law on the following day. This filing is deemed an emergency and is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes of 2013, section 77.
22. Certificate of Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed 6/10/2014 (Register 2014, No. 24).