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The household composition rules outlined in this letter apply to all MAGI Medi-Cal coverage groups below: • New Adult Group (adults aged 19 to 64 and not Medicare eligible); • Parent/Caretaker Relative Group (including pregnant individuals in their third trimester); o Note: California Work Opportunity and Responsibility for Kids (CalWORKS) parents/caretaker relatives are covered under this eligibility group • Mandatory Children’s Groups • Optional Targeted Low-Income Children’s Program (OTLICP); • Pregnant Women and Infant programs; • Medi-Cal Access Program (MCAP); and • Medi-Cal Access Infant-Linked Program (MCAIP)

The following policy areas will be included in this ACWDL. Due to the size of this ACWDL, the corresponding page numbers have been included next to the subject title for navigation purposes. • I. MAGI Medi-Cal Household Composition and Tax Filing Rules Page 02 • II. Required Tax Filing Information for MAGI

Page 06 • III. Obtaining and Verifying Tax Filing Information Page 07 • IV. MAGI Medi-Cal Household Composition Scenarios

Page 10 • V. Complex Households and Special Populations

Page 20

I. MAGI Medi-Cal Household Composition and Tax Filing Rules MAGI Medi-Cal follows the federal tax filing rules as a framework to determine an individual’s MAGI Medi-Cal household composition based on their tax filing status (42 C.F.R. Section 435.603).

DHCS, in coordination with the Centers for Medicare & Medicaid Services (CMS), created a MAGI Medi-Cal Household Size Flowchart for use when calculating MAGI Medi-Cal household compositions. Counties may use the “DHCS MAGI Household Size Flow Chart” when constructing an individual’s MAGI Medi-Cal household composition. In addition, CalHEERS uses the same flowchart to determine MAGI Medi-Cal household compositions.

MAGI methodology requires the construction of MAGI Medi-Cal household compositions to be on an individual basis for each household member, because in some situations, there is the potential for each individual in the household to have a

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different household composition than others on the same case. Unlike other Medi-Cal programs, beneficiaries of SSI/SSP, CalWORKS, or those in long-term care should be included, when appropriate, into an individual’s MAGI household composition.

The CEW shall determine the individual’s MAGI household composition based on the following tax filing status rules as referenced in 42 C.F.R. Section 435.603: • Tax Filer Rules; • Tax Dependent Rules; • Tax Dependent Exceptions; and • Non-Filer Rules.

Note: Household composition methodology for Covered California programs is based on tax filing rules found in 26 C.F.R. Section 1.36B-1 and should not be confused with MAGI Medi-Cal household composition methodology.

Tax Filer Rules Tax Filer Rules apply to individuals who expect to file a federal tax return and another tax filer does not claim them as a tax dependent for the year in which MAGI Medi-Cal is sought. As defined in 42 C.F.R. Section 435.603(f)(1) and (4), the household composition of a tax filer not claimed as a tax dependent shall consist of: 1) The tax filer; 2) The spouse of the tax filer who lives in the home, regardless of whether they are filing a joint return; 3) Married couples who are living together (Note: this group is always in each other’s household regardless of how they file); 4) The spouse of tax filer who files “Married Filing Jointly” but who does not live in the home; 5) Everyone the tax filer claims as a tax dependent, regardless of whether they reside in the home of the tax filer; and/or 6) The unborn child(ren) of the pregnant tax filer, the unborn child(ren) of the pregnant spouse if living in the home or filing taxes as “Married Filing Jointly”, or the unborn child(ren) of a pregnant tax dependent in the individual’s household composition.

It is possible for some individuals to claim tax dependent(s) that do not reside in the home, including dependents that reside in another country. The CEW shall include all

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dependents, regardless of where they reside, when determining the MAGI Medi-Cal household composition.

Basic Rules for Married Individuals Whenever a couple is married and expect to file a joint tax return, regardless of whether they are living together in the same home, the spouses will be counted in each other’s household for the purposes of making a MAGI Medi-Cal determination in accordance with 42 C.F.R. Section 435.603(f)(1) and (4).

However, if the spouses will not be filing jointly in the next year, it will be considered a reasonable predictable change in income consistent with 42 C.F.R. Section 435.603(h)(3), and the spouses will not be required to be included in each other’s MAGI Medi-Cal household.

Basic Rules for Individuals Claimed as a Tax Dependent Tax Dependent Rules apply to individuals who expect to be claimed as a tax dependent and do not meet any of the dependent exceptions (detailed below in “Tax Dependent Exceptions” section). It is important to note tax dependents can file their own taxes in addition to being a tax dependent. As defined in 42 C.F.R. Section 435.603(f)(2), the household composition of a tax dependent shall consist of: 1) The tax filer; 2) The spouse of the tax filer who lives in the home; 3) The spouse of the tax filer who files as “Married Filing Jointly” who does not live in the home; 4) Everyone the tax filer claims as a tax dependent; and/or 5) The unborn child(ren) of a pregnant tax dependent, the unborn child(ren) of a pregnant tax filer(s) if living in the home or filing taxes as “Married Filing Jointly,” or the unborn child(ren) of another pregnant tax dependent in the individual’s household composition. Unless one of the exceptions applies (discussed in the section below titled “Tax Dependent Exceptions”), the household composition of a tax dependent is generally the same as the tax filer claiming such individual as a tax dependent.

Tax Dependent Exceptions When determining MAGI Medi-Cal eligibility for tax dependents, the CEW shall determine if the individual(s) meets a tax dependent exception. If an individual meets one of the following exceptions, the CEW must apply the Non-Filer Rules (detailed below in “Non-Filer Tax Rules”) to construct the individual’s household composition.

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As defined in 42 C.F.R. Section 435.603(f)(2), exceptions for tax dependents are as follows: 1) The tax dependent (of any age) is someone other than the spouse or child of the tax filer; or 2) The tax dependent is under the age of 19, or under the age of 21 and a full time student, who lives with both parents, but the parents do not expect to file a joint tax return; or 3) The tax dependent is under the age of 19, or under the age of 21 and a full time student, who will be claimed as a tax dependent by a non-custodial parent (for joint custody situations, see section “Complex Household and Special Populations” below).

Non-Filer Rules Non-Filer Rules apply to individuals who do not expect to file a tax return nor be claimed as a tax dependent, or to individuals who are a tax dependent that meet one of the exceptions listed in the “Tax Dependent Exceptions” section above. As defined in 42 C.F.R. Section 435.603(f)(3), the household composition for non-filers who are not claimed as a tax dependent or who meet a tax dependent exception shall consist of the below members, broken down by the non-filer’s situation. • If a non-filer adult (over age 19 and not a full-time student): 1) The individual; 2) The individual’s spouse (if living in the home); and/or 3) The individual’s child(ren) (biological, step, or adopted) under age 19, or under age 21 and a full-time student (if living in the home). • If a non-filer child under age 19, or full-time students under age 21: 1) The child; 2) The child’s spouse (if living in the home) 3) The child’s biological, step or adoptive child(ren) under 19 years of age, or under the age of 21 and a full-time student (if living in the home) 4) The child’s biological, step, or adoptive parents (if living in the home); and/or 5) The child’s siblings (biological, step, or adopted) under age 19, or a full time student under age 21 (If living in the home).

Future Changes or When Tax Filing Status is Uncertain In situations where there is uncertainty about the tax dependent filing status of an individual such as when an applicant or beneficiary is unsure if they are claimed as a tax dependent by a tax filer or if a tax filer cannot reasonably establish another

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individual is a tax dependent of the tax filer for the year in which MAGI Medi-Cal is requested, the CEW shall use Non-Filer Rules to determine the MAGI household composition as outlined in 42 C.F.R. Section 435.603(f)(5).

Additionally, in situations where the applicant or beneficiary reasonably predicts a change in their tax filing status, CEWs shall use the reasonably predictable future changes to establish the household composition. CMS has provided clarification that the flexibilities outlined in 42 C.F.R. Section 435.603(h)(3) include future tax filing status changes as they are the basis for the income counting rules. CEWs shall follow existing self-attestation rules for gathering tax filing information outlined below.

II. Required Tax Filing Information for MAGI Medi-Cal Household Compositions MAGI Medi-Cal household composition methodology follows the federal tax filing rules explained above as a framework to determine household compositions for all MAGI Medi-Cal based programs. In order to be eligible for MAGI Medi-Cal, individuals are not required to file a federal tax return. However, individuals are required to provide information on how they plan on filing federal taxes for the year in which they are seeking coverage, even if they do not plan on filing taxes (i.e. non-filers).

This information is necessary during the application process, as well as annual renewal and changes in circumstances to create a MAGI Medi-Cal household composition. At any redetermination, either at annual renewal or a change in circumstance, the beneficiary shall have an opportunity to review the tax filing information and report changes on their tax filing status (i.e. how the individual plans on filing taxes and/or if they will be claimed as a tax dependent) of anyone in the household. Required tax information for every individual in the MAGI Medi-Cal household are: • Who is the primary tax filer (the first name listed on the tax return); • If the individual expects to file taxes; • If the individual is expected to be required to file taxes; • The individual’s tax filing status (i.e., Head of Household, Married Filing Jointly, Married Filing Separately, Single, or not filing taxes, i.e. non-filer); and • If claimed as a tax dependent, the name of the tax filer claiming the individual as a dependent.

As a reminder, CEWs shall review and update the tax filing information for all household members at application, annual renewal, or when a change in circumstance occurs (such as a person moves into or out of the home, a child is born, or there is an increase or decrease in income). If an individual is unsure how they or others on the case will file federal taxes, or if they are required to file federal taxes, the CEW may refer them to the

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Internal Revenue Service (IRS) or the individual may consult a local tax professional for assistance. CEWs may reference ACWDL 17-30 for questions on IRS or tax professional referrals.

Note: For Covered California eligibility for federal premium tax credits, known as Advanced Premium Tax Credits (APTC), individuals are required to file a federal tax return in order to be eligible for federal premium tax credits, known as Advance Payments of Premium Tax Credit (APTC). In addition, individuals are required to file a state tax return to be eligible for the new California State Premium Assistance Subsidy, which began on January 1, 2020.

III. Obtaining and Verifying Tax Filing Information (i.e. Tax Filing Status) Clarifications to existing policy are detailed below in regards to self-attestation, signature requirements, ex parte review, and failure to provide tax information. This letter is not providing new policy on these areas, but instead is intended to bridge any gaps between previously established policy and MAGI household composition.

Self-Attestation of Tax Information Per ACWDL 17-16, when obtaining how an individual files taxes or who is claimed as a tax dependent, CEWs shall accept the individual’s self-attestation. The CEW shall use self-attested information and follow the MAGI Medi-Cal household composition framework rules detailed above when constructing the MAGI Medi-Cal household composition of an individual. The Federal Data Services Hub (FDSH), via CalHEERS, does not verify tax filing information due to the acceptance of self-attestation.

The self-attested tax filing information does not expire and shall not change unless the applicant/beneficiary reports a change to their tax filing information to counties. This includes how an individual plans on filing taxes and if they are a dependent on someone else’s federal taxes.

Obtaining Self-Attested Tax Information CEWs may obtain self-attested tax filing information through the following methods at application, annual renewal or change of circumstance if self-attestation is unavailable: • Single Streamline Application (online or paper application) • Telephone/Fax • Mail • SAWS 2 Plus (online or paper application) • Applicant/beneficiary’s preferred electronic method

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• Past declarations made by the applicant/beneficiary known by the county

• Request for Tax Household Information (RFTHI) form Signature Requirements Counties shall continue to follow guidance on acceptable methods for form signatures as detailed in ACWDL 19-17. All forms that require a signature must have a signature, which includes telephonic signatures that the CEW may obtain over the phone. Per ACWDL 19-17, if the CEW has obtained a telephonic signature, the applicant/beneficiary is not also required to return the form with a wet signature.

Ex Parte Review Per Welfare and Institutions Code (WIC) 14013.3 and WIC 14005.37, prior to requesting additional information from an applicant or beneficiary, CEWs must first conduct a manual ex parte review of the case. As a reminder, counties are required to review all available applicant and beneficiary information in the attempt to obtain tax household information as a part of the manual ex parte review. This review may include, but is not limited to, information from other programs (i.e. CalWORKS and CalFresh) or previously reported information. The manual ex parte process shall not require individuals to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary. For further information on the ex parte process, counties may reference ACWDL 14-32.

Failure to Provide Tax Filing Information If an individual fails to provide tax filing information, counties shall continue to follow current policy guidance about failure to provide information. If at application, annual renewal, or change in circumstance redetermination, the CEW is unable to obtain the tax filing status, the CEW shall deny or discontinue the case for failure to provide requested tax household information. The CEW shall follow the policies and procedures on how to discontinue a case for failure to provide information located in ACWDLs 15- 27, 16-04, and 18-24. However, if an individual is unsure how they will file taxes in the year for which coverage is sought, CEWs shall use Non-Filer Rules per 42 C.F.R 435.603(f).

As outlined in ACWDL 15-27, the CEW shall provide specific information the individual failed to provide on the Notice of Action (NOA).

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Contradictions in Tax Filing Status In some circumstances, counties may receive self-attested tax filing information from an individual that conflicts with other information reported, such as unmarried individuals who self-attest to expecting to file taxes as “Married Filing Jointly” or two individuals that self-attest to claiming the same dependent.

In certain circumstances, when conflicting self-attested tax filing status information is received, the CEW shall follow 42 C.F.R. Section 435.603(f)(5) and construct the MAGI Medi-Cal household composition based on Non-Tax Filer Rules. CEWs shall only use this in the following instances: • Where individuals are unmarried but filing taxes as “Marred Filing Jointly” (MEDIL 19-24); or • If a tax filer is unsure if another individual will be their tax dependent for the tax year in which MAGI Medi-Cal coverage is sought.

For MAGI Medi-Cal household composition purposes, CEWs can accept verification of relationships between household members (such as spouses, registered domestic partners, etc.) via self-attestation. However, an individual is not considered to be married until the marriage has actually occurred (see 42 C.F.R. Section 435.945 and California Family Code Section 300). Any future marriage, including a future marriage by the end of the current tax year, is a change in circumstance and the beneficiary shall report this change within 10 days of the legal relationship change. CEWs may reference ACWDL 17-27 for information regarding same sex married individuals.

Household Composition Rules for Covered California Covered California household composition closely follows Tax Filer Rules as defined in 26 C.F.R. Section 1.36B-1(d). Household composition for Covered California eligibility determinations includes: • The primary tax filer (the first person listed on the tax return); • The primary tax filer’s spouse; and/or • Any tax dependent(s).

Spouses and tax dependents are included in the household composition even if they are not applying for health insurance. Married couples must attest that they will file a joint tax return to be eligible for financial assistance through Covered California. Legally separated or divorced spouse are not included in the household of the tax filer. The tax filer does not have to include their spouse if they are a victim of intimate partner violence or spousal abandonment.

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For Covered California, dependent children are included in the household regardless of their age if the tax filer will claim them as a tax dependent. Non-dependent children under the age of 26 are included in the household if the tax filer intends to cover them on their Covered California plan. Other relatives living with the tax filer, such as parents, siblings, or other relatives, are only included in the household if the tax filer will claim them as tax dependents.

IV. MAGI Medi-Cal Household Composition Scenarios The intent of the scenarios below is to assist counties in understanding MAGI Medi-Cal household composition. Each scenario goes through the appropriate steps and mirrors the language on the “DHCS MAGI Household Size Flow Chart” to determine the correct household composition for every individual in the scenario.

Scenario 1: Married Couple with Mutual Child (Age 10) and Separate Child (Age 13) Married couple (Spouse 1 and Spouse 2) is living together with one mutual child (Child 1) and Spouse 2’s separate child (Child 2). Both children are under the age of 18. Spouse 1 and Spouse 2 plan to file a joint tax return and will claim both Child 1 and Child 2 as tax dependents. This scenario reviews Tax Flier Rules and Tax Dependent Rules.

Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: Household consists of Spouse 1 and all those they claim as a tax dependent. (Child 1 and Child 2). 4) Is Spouse 1 married? Yes. 5) Are Spouse 1 and Spouse 2 living apart and filing separately? No (Include Spouse 2 in the household composition). 6) Is Spouse 1 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

Spouse 2’s Household Composition: 1) Does Spouse 2 expect to file a federal tax return? Yes. 2) Does Spouse 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 2 qualifies for Tax Filer Rules: household consists of Spouse 2, and all those Spouse 2 claims as a tax dependent. (Child 1 and Child 2)

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4) Is Spouse 2 married? Yes. 5) Is Spouse 2 and Spouse 1 living apart and filing separately? No (Include Spouse 1 in the household composition). 6) Is Spouse 2 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

Child 1’s Household Composition: 1) Does Child 1 expect to file a federal tax return? No. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 1 meet one of the exceptions? No. 4) Child 1 qualifies for Tax Dependent Rules: household consists of the dependent, the people claiming the tax dependent, and all others the tax filer claims as a dependent (Spouse 1, Spouse 2, Child 1 and Child 2). 5) Is Child 1 married? No. 6) Is Child 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional changes, end household composition determination here.

Child 2’s Household Composition: 1) Does Child 2 expect to file a federal tax return? No. 2) Does Child 2 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 2 meet one of the exceptions? No. 4) Child 2 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax payer claims as a dependent (Spouse 1, Spouse 2, Child 1 and Child 2) 5) Is Child 2 married? No. 6) Is Child 2 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here. Medi-Cal Household Spouse 1 Spouse 2 Child 1 Child 2 Family Size Spouse 1 Included Included Included Included 4 Spouse 2 Included Included Included Included 4 Child 1 Included Included Included Included 4 Child 2 Included Included Included Included 4

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Scenario 2: Married Pregnant Couple with Child (Age 11) and Dependent (Age 66) Spouse 1 (who is pregnant) and Spouse 2 are living together and plan to file joint tax return and claim as tax dependents one mutual child (Child 1) who is under the age of 18 and Spouse 1’s parent over 65 years of age (Grandparent). This scenario reviews Tax Filer Rules, Tax Dependent Rules, and an individual who does not meet MAGI Medi-Cal eligibility criteria. Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: household consists of Spouse 1 and all those claimed as a tax dependent. (Child 1 and Grandparent). 4) Is the individual married? Yes. 5) Are Spouse 1 and Spouse 2 living apart and filing separately? No (Include Spouse 2 in the household composition). 6) Is the individual Pregnant? Yes. 7) Are any people who are included in the individual’s household composition pregnant? No. 8) No additional change, end household composition determination here.

Spouse 2’s Household Composition: 1) Does Spouse 2 expect to file a federal tax return? Yes. 2) Does Spouse 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 2 qualifies for Tax Filer Rules: household consists of Spouse 2 and all those claimed as a tax dependent (Child 1 and Aged Dependent). 4) Is the individual married? Yes. 5) Is Spouse 2 and Spouse 1 living apart and filing separately? No (Include Spouse 1 in the household composition). 6) Is the individual Pregnant? No. 7) Are any people who are included in the individual’s household composition pregnant? Yes. 8) No additional change, end household composition determination here.

Child 1’s Household Composition: 1) Does Child 1 expect to file a federal tax return? No. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does the Child 1 meet one of the exceptions? No.

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4) Child 1 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax filer claims as a dependent (Spouse 1, Spouse 2, Child 1 and Grandparent). 5) Is the child married? No. 6) Is the child pregnant? No. 7) Is anyone included in the household pregnant? Yes. 8) No additional change, end household composition determination here.

Grandparent Household Composition:

The grandparent will be ineligible for MAGI Medi-Cal because they do not meet the age requirements of MAGI Medi-Cal eligibility (42 C.F.R. Section 435.603(j)) and is not a caretaker relative. Grandparent, if applying for Medi-Cal services, shall be evaluated for the Non-MAGI Medi-Cal program. However, the grandparent is included on this case because they are a tax dependent of the primary tax filer and will be used in the household composition for other members of the household

Medi-Cal Household Spouse 1 Spouse 2 Child 1 Grandparent Family Size Spouse 1 Included Included Included Included 5(unborn included) Spouse 2 Included Included Included Included 5(unborn included) Child 1 Included Included Included Included 5(unborn included)

Scenario 3: Married Couple with Mutual Child (Age 11) and Grandparent (age 63) A married couple (Spouse 1 and Spouse 2) is living together, plans to file joint tax return and claim as tax dependents: one mutual child (Child 1) who is under the age of 18 and Spouse 1’s parent (Grandparent) who is age 63. This scenario reviews Tax Filer Rules, Tax Dependent Rules, and Non-Filer Rules.

Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: household consists of the Spouse 1, and all those claimed as a tax dependent. (Child 1 and Grandparent) 4) Is Spouse 1 married? Yes.

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5) Is Spouse 1 and his spouse living apart and filing separately? No (Include Spouse 2 in the household composition) 6) Is Spouse 1 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

Spouse 2’s Household Composition: 1) Does Spouse 2 expect to file a federal tax return? Yes. 2) Does Spouse 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 2 qualifies for Tax Filer Rules: household consists of the Spouse 2 and all those claimed as a tax dependent (Child 1 and Grandparent). 4) Is Spouse 2 married? Yes 5) Is Spouse 2 and their spouse living apart and filing separately? No (Include Spouse 1 in the household composition). 6) Is Spouse 2 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

Child 1’s Household Composition:

1) Does Child 1 expect to file a federal tax return? No. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 1 meet one of the exceptions? No. 4) Child 1 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax payer claims as a dependent (Spouse 1, Spouse 2, Child 1 and Grandparent) 5) Is Child 1 married? No. 6) Is Child 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here.

Grandparent’s Household Composition:

1) Does Grandparent expect to file a federal tax return? No. 2) Does Grandparent expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Grandparent meet one of the exceptions? Yes (meets exception 1 because Grandparent is not the child or spouse of Spouse 1 or Spouse 2)

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4) Grandparent qualifies for Non-Filer Rules: household consists of the following people living with the individual: individual’s spouse and the individual’s child(ren) (natural, adopted, or step) that are under age 19, or if a full time student under age 21. (Grandparent only) 5) Is the grandparent pregnant? No. 6) Is anyone included in the household pregnant? No. 7) No additional change, end household composition determination here.

Medi-Cal Household Spouse 1 Spouse 2 Child 1 Grandparent (Under 65) Family Size Spouse 1 Included Included Included Included 4 Spouse 2 Included Included Included Included 4 Child1 Included Included Included Included 4 Grandparent (Under 65) Not Included Not Included Not Included Included 1

Scenario 4: Married Couple with Mutual Children (Age 18, 22, and 23). None of the Children Reside in the Home with the Parents A married couple (Spouse 1 and Spouse 2) is living together, plan to file joint tax return and claim as tax dependents three mutual children (Child 1 is 18 years old, Child 2 is 22 years old, and Child 3 is 23 years old). Child 1 and Child 3 do not expected to file a tax return, but Child 2 expects to file a tax return. This scenario reviews Tax Filer Rules and Tax Dependent Rules.

Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: household consists of the Spouse 1, and all those claimed as a tax dependent (Child 1, Child 2, and Child 3). 4) Is Spouse 1 married? Yes. 5) Is Spouse 1 and Spouse 2 living apart and filing separately? No (Include Spouse 2 in the household composition). 6) Is Spouse 1 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

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Spouse 2’s Household Composition: 1) Does Spouse 2 expect to file a federal tax return? Yes. 2) Does Spouse 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 2 qualifies for Tax Filer Rules: household consists of Spouse 2, and all those claimed as a tax dependent. (Child 1, Child 2, and Child 3) 4) Is Spouse 2 married? Yes. 5) Is Spouse 2 and his spouse living apart and filing separately? No (Include Spouse 1 in the household composition). 6) Is Spouse 2 pregnant? No. 7) Is anyone included in the household composition pregnant? No. 8) No additional changes, end household composition determination here.

Child 1’s (age 18) Household Composition: 1) Does Child 1 expect to file a federal tax return? No. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 1 meet one of the exceptions? No. 4) Child 1 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax filer claims as a dependent (Spouse 1, Spouse 2, Child 1, Child 2, and Child 3) 5) Is Child 1 married? No. 6) Is Child 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here.

Child 2’s (age 22) Household Composition: 1) Does Child 2 expect to file a federal tax return? Yes. 2) Does Child 2 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 2 meet one of the exceptions? No. 4) Child 2 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax filer claims as a dependent (Spouse 1, Spouse 2, Child 1, Child 2, and Child 3) 5) Is Child 2 married? No. 6) Is Child 2 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here. Note: Even though Child 2 expects to file a federal tax return, their MAGI Medi-Cal household remains the same because none of the exceptions apply to their situation.

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Child 3’s (age 23) Household Composition: 1) Does Child 3 expect to file a federal tax return? No. 2) Does Child 3 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 3 meet one of the exceptions? No. 4) Child 3 qualifies for Tax Dependent Rules: household consists of the dependent, the person claiming the dependent, and all others the tax filer claims as a dependent (Spouse 1, Spouse 2, Child 1, Child 2, and Child 3) 5) Is Child 3 married? No. 6) Is Child 3 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here.

Medi-Cal Household Spouse 1 Spouse 2 Child Child 2 Child 3 Family Size Spouse 1 Included Included Included Included Included 5 Spouse 2 Included Included Included Included Included 5 Child 1 Included Included Included Included Included 5 Child 2 Included Included Included Included Included 5 Child 3 Included Included Included Included Included 5

Scenario 5: Unmarried Couple with Mutual Child (Age 8), and One Child (age 10) Claimed by a Non-Custodial Parent (Neither Person 1 or Person 2) Unmarried couple (Person 1 and Person 2) is living together and both plan to file taxes as single. Person 1 claims the mutual child (Child 1) as a tax dependent, and Person 2 has a separate child (Child 2) living in the home claimed as a tax dependent by a non- custodial parent. Both children are under 18. This scenario reviews Tax Filer Rules, Tax Dependent Rules, and Non-Filer Rules.

Person 1’s Household Composition: 1) Does Person 1 expect to file a federal tax return? Yes. 2) Does Person 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Person 1 qualifies for Tax Filer Rules: household consists of Person 1 and all those Person 1 claims as a tax dependent (Child 1). 4) Is Person 1 married? No. 5) Is Person 1 pregnant? No. 6) Is anyone included in the household composition pregnant? No. 7) No additional changes, end household composition determination here.

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Person 2’s Household Composition: 1) Does Person 2 expect to file a federal tax return? Yes. 2) Does Person 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Person 2 qualifies for Tax Filer Rules: household consists of Person 2 and all those Person 2 claims as a tax dependent (Only Person 2). 4) Is Person 2 married? No. 5) Is Person 2 pregnant? No. 6) Is anyone included in the household composition pregnant? No. 7) No additional changes end household composition determination here.

Child 1’s (age 8) Household Composition: 1) Does Child 1 expect to file a federal tax return? No. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 1 meet one of the exceptions? Yes (Meets exception 2 because they live with both parents but they do not expect to file a joint return). 4) Child 1 qualifies for Non-Filer Rules: household consists of the following people living with the individual: individual’s parents (natural, adopted, or step) and the individual’s siblings (natural, adopted, or step) that are under age 19, or if a full time student under age 21 (Person 1, Person 2, Child 1 and Child 2). 5) Is Child 1 married? No. 6) Is Child 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change end household composition determination here.

Child 2’s (age 10) Household Composition: 1) Does Child 2 expect to file a federal tax return? No. 2) Does Child 2 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does Child 2 meet one of the exceptions? Yes (Meets the third exception on the household size flow chart because Child 2 is claimed by a non-custodial parent). 4) Child 2 qualifies for Non-Filer Rules: household consists of the following people living with the individual: individual’s parents (natural, adopted, or step) and the individual’s siblings (natural, adopted, or step) that are under age 19, or if a full time student under age 21. (Person 2, Child 1 and Child 2. Note: Person 2 and Person 1 are not married, Person 1 is not Child 2’s stepparent so Person 1 is not included in Child 2’s household) 5) Is Child 2 married? No. 6) Is Child 2 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change end household composition determination here.

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Medi-Cal Household Person 1 Person 2 Child 1 Child 2 Family Size Person 1 Included Not Included Included Not Included 2 Person 2 Not Included Included Not Included Not Included 1 Child 1 Included Included Included Included 4 Child 2 Not Included Included Included Included 3

Scenario 6: Single Parent with Married Dependents Single Parent (Person 1), age 40, is claiming their married adult child (Spouse 1) as a dependent but is not claiming the other spouse (Spouse 2). Person 1, Spouse 1, and Spouse 2 all live in the same home. Spouse 1 and Spouse 2 are married, both aged 18 years old, and are non-filers. This scenario reviews Tax Filer Rules, Tax Dependent Rules, and Non-Filer Rules.

Person 1’s Household Composition: 1) Does Person 1 expect to file a federal tax return? Yes. 2) Does Person 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Person 1 qualifies for Tax Filer Rules: household consists of Person 1 and all those claimed as a tax dependent (Person 1 and Child Spouse 1). 4) Is Person 1 married? No. 5) Is Person 1 pregnant? No. 6) Is anyone included in the household composition pregnant? No. 7) No additional changes, end household composition determination here.

Spouse 1’s (Age 18) Household Composition: 1) Does Spouse 1 expect to file a federal tax return? No. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? Yes. 3) Does Spouse 1 meet one of the exceptions? No. 4) Spouse 1 qualifies for Tax Dependent Rules: household consists of child Spouse 1, Person 1 and all those the tax filer claims as a tax dependent. (Person 1 and Spouse 1) 5) Is Spouse 1 married? Yes. 6) Is Spouse 1 and their spouse living apart and filing separately? No (Add Spouse 2, household now consists of Person 1, Spouse 1 and Spouse 2) 7) Is Child Spouse 1 pregnant? No. 8) Is anyone included in the household composition pregnant? No.

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9) No additional changes, end household composition determination here.

Spouse 2’s (Age 18) Household Composition: 1) Does Child Spouse 2 expect to file a federal tax return? No. 2) Does Child Spouse 2 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 2 qualifies for: Non-Filer Rules: household of a non-filer child consists of the individual and the following people living with the individual: individual’s parent(s) (natural, adopted or step), individual’s siblings that are under age 19, or under age 21 if a full time student (natural, adopted, half or step), individual’s spouse and the individual’s children (natural, adopted, or step) that are under age 19, or under age 21 if a full time student (Spouse 1 and Spouse 2). 4) Is Spouse 2 pregnant? No. 5) Is anyone included in the household composition pregnant? No. 6) No additional changes, end household composition determination here.

Medi-Cal Household Parent 1 Child Spouse 1 Child Spouse 2 Family Size Parent 1 Included Included Not Included 2 Spouse 1 Included Included Included 3 Spouse 2 Not Included Included Included 2

V. Complex Households and Special Populations CMS identified certain complex household scenarios where current federal law does not explicitly outline the composition rules. Listed below are six different scenarios, and the methodologies used to construct the household compositions. CMS also provided policy guidance on the MAGI Medi-Cal household compositions for these complex households in a CMS training presentation titled ‘MAGI 2.0: Building MAGI Knowledge, Part 1 Household Composition’ dated July 21, 2016 Counties shall use the scenarios below as a reference tool when constructing household compositions of complex households or special populations as outlined below. 1) Victims of Intimate Partner Violence 2) Institutionalized Children 3) Joint Custody 4) Child Tax Filer Living with Parent 5) Homeless Youth 6) Separated Spouses Filing Jointly

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1) Victims of Intimate Partner Violence An individual who is a victim of intimate partner violence may change how they plan on filing taxes, depending on the circumstances. The CEW may work with the individual to determine how they plan on filing taxes in the future and the appropriate method to determine household composition. Below explains how to treat victims of intimate domestic violence with various tax filing statuses. • Married Filing Jointly: In situations where the victim of intimate partner violence plans to file taxes as “Married Filing Jointly” in the current year but self-attest that they will not file “Married Filing Jointly” in the next year, CEWs may use the “reasonably predictable changes in income” rule referenced in the “Future Changes or When Tax Filing Status is Uncertain” section above so that the individual’s spouse will not be included in the household composition. The CEW will base the household composition on how the individual anticipates filing taxes in the future as allowed per 42 C.F.R. Section 435.603(h)(3). • Married Filing Separately: If the individual self-attests that they plan on filing taxes as “Married Filing Separately,” the CEW shall not include the spouse of the victim of intimate partner violence in the household composition. • Unsure of how they will file taxes: To the extent that the individual is in a transitional situation and unsure how they plan to file taxes, the CEW shall apply the Non-Filer Rules. Non-Filer Rules count children in the household of the parent with whom they are living.

Note: For Covered California program eligibility, if a victim of intimate partner violence states that they are self-attesting to planning to file taxes as “Married Filing Separately,” Covered California staff is instructed to have the consumer choose “single” or “head of household” on the application so they can receive APTC. CMS approved this process.

Example: Victims of Intimate Partner Violence: Married victim (Person 1) of intimate partner violence is aged 27 and unsure how they will file taxes.

Victim of Intimate Partner Violence Household Composition: 1) Does Individual 1 expect to file a federal tax return? Unsure/Don’t Know. 2) Does Individual 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Individual 1 qualifies for Non-Filer Rules: household consists of the victim of an intimate partner violence and all natural, adopted, or step children under 19 or under 21 if a full time student (Individual 1, spouse is not included in household).

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4) Is anyone in the household composition pregnant? No. 5) Is anyone included in the household composition pregnant? No. 6) No additional changes, end household composition determination here.

Medi-Cal Household Victim of an intimate partner Spouse Family Size Person 1 Included Not Included 1

Note: For Covered California program eligibility, the tax household size cannot be determined. Individuals must attest to self-attest to planning to file taxes in order to be eligible for financial assistance through Covered California.

2) Institutionalized Children For a child that resides outside of a parent’s home in an institutional facility such as a psychiatric hospital, penal institution, or children’s home facility and is requesting Medi- Cal coverage, the household composition will vary depending on if the child will be claimed as a tax dependent. Detailed below is guidance on how to evaluate institutionalized children with various tax filing statuses. • Institutionalized child claimed as a tax dependent: If the child living in an institution and is claimed as a tax dependent, the county shall follow the Tax Dependent Rules outlined in the “MAGI Household Composition and Tax Filing Rules” section above when determining eligibility. If the child is not MAGI Medi-Cal eligible based on the parent’s income, the CEW shall evaluate the child for Non- MAGI Medi-Cal and the child’s parent(s) may be excluded in the Medi-Cal determination pursuant to California Code of Regulations (C.C.R.), Title 22, Sections 50373 and 50381. • Institutionalized child not claimed as a tax dependent: If no one claims the institutionalized child as a tax dependent or if the institutionalized child is unsure of their expected filing status, the Non-Filer Rules shall be used to determine household composition for MAGI Medi-Cal eligibility. As a result, the child’s parent(s) would not be included in the household composition.

Note: In circumstances where the child will be claimed as a tax dependent of their parent but the county is unable to obtain the tax information needed to determine eligibility the household composition shall be determined based on Non-Filer Rules as permitted by 42 C.F.R. Section 435.603(f)(5).

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Institutionalized Child Example: Institutionalized Child (age 14) not claimed as a tax dependent.

Institutionalized Child’s Household Composition: 1) Does Institutionalized Child expect to file a federal tax return? No. 2) Does Institutionalized Child expect be claimed as a tax dependent by another tax filer? No. 3) Institutionalized Child qualifies for Non-Filer Rules: household consists of the following people living with the individual: individual’s parents (natural, adopted, or step), the individual’s siblings (natural, adopted, half or step) that are under age 19, or if a full time student under age 21; individual’s spouse, and individual’s children (natural, adopted, or step). (Institutionalized Child, no other household members) 4) Is anyone in the household composition pregnant? No. 5) No additional changes, end household composition determination here.

Medi-Cal Household Parent 1 Parent 2 Child Family Size Institutionalized Child Not Included Not Included Included 1

3) Joint Custody and Determining the Custodial Parent Per 42 C.F.R. Section 435.603 (f)(2)(iii)(B) in scenarios where both parents share joint custody of a child(ren), regardless of whether a formal custody agreement exists, AND one or both parents request Medi-Cal coverage for the child(ren), the CEW must determine which parent is considered the custodial parent for determining Medi-Cal eligibility (see 25 C.F.R. Section 700.51 for the definition of a custodial parent). In order to determine the custodial parent, the CEW must determine the primary caregiver of the child(ren). The primary caregiver is typically the parent with whom the child(ren) spends the most nights.

When both parents are applying separately for health coverage for the same child(ren) in the same year, the child(ren) shall have Medi-Cal eligibility determined based on which parent has primary care of the child(ren). However, when both parents apply separately for health coverage for the same child(ren) and both parents claim to have shared custody with the child(ren) and the child spends equal nights with each parent, then the child(ren) are in the household of the parent who first applied for Medi-Cal, including Medi-Cal through CalWORKs (see ACWDL 86-60 for more information).

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In joint custody situations where the person claiming the child as a tax dependent that does not have primary care, the child shall have their household composition based on the household of the parent who has primary care using the Non-Filer Rules.

Joint Custody Example: A parent (Parent 1) is age 35 and has primary care of their child (Child 1), who is age 12. Parent 1 is not planning to file taxes and Child 1 is claimed as a tax dependent by the non-custodial parent not in the home.

Parent 1’s Household Composition: 1) Does Parent 1 expect to file a federal tax return? No. 2) Does Parent 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Parent 1 qualifies for Non-Filer Rules: household consists of Parent 1 and all natural, adopted, or step children under 19 or under 21 if a full time student. (Parent 1 and Child 1) 4) Is Parent 1 pregnant? No. 5) Is anyone included in the household composition pregnant? No. 6) No additional changes, end household composition determination here.

Child 1’s Household Composition: 1) Does the Child 1 expect to file a federal tax return? No. 2) Does the Child 1 expect be claimed as a tax dependent by another tax filer? Yes. 3) Does the Child 1 meet one of the exceptions? Yes (Meets exception 3) 4) Child 1 qualifies for Non-Filer Rules: household consists of the child, child’s parents, and all natural, adopted, or step children under 19 or under 21 if a full time student. (Parent and Child 1) 5) Is the child pregnant? No. 6) Is anyone included in the household composition pregnant? No. 7) No additional changes, end household composition determination here.

Medi-Cal Household Parent 1 Child 1 Family Size Parent 1 Included Included 2 Child 1 Included Included 2

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Child Tax Filer Living with a Parent A child (under age 19 or under 21 if a full-time student) who files their own taxes, lives at home with their parent(s), and is not claimed as a tax dependent by a parent(s), shall have their MAGI household composition based on the Tax Filer Rules regardless of whether the child is residing in the home with their parent(s). Because the parent is not claiming the child as a tax dependent, the parent’s tax filing information is not used the in the child’s MAGI Medi-Cal eligibility determination.

Child Tax Filer Living with Parent Example: A parent (Parent 1) and their 18-year old child (Child 1) live together in the same home. Parent 1 and Child 1 both file separate tax returns as “Single.” Child 1 is not claimed as a tax dependent by anyone.

Parent 1’s Household Composition: 1) Does the Parent 1 expect to file a federal tax return? Yes. 2) Does the Parent 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Does the Parent 1 meet one of the exceptions? No. 4) Parent 1 qualifies for Tax Filer Rules: household consists of tax payer, and all others the tax payer claims as a dependent (Parent 1 only) 5) Is parent married? No. 6) Is parent pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here.

Child 1’s Household Composition: 1) Does Child 1 expect to file a federal tax return? Yes. 2) Does Child 1 expect be claimed as a tax dependent by another tax filer? No. 3) Does Child 1 meet one of the exceptions? No. 4) Child 1 qualifies for Tax Filer Rules: household consists of tax payer, and all others the tax payer claims as a dependent (Child 1). 5) Is Child 1 married? No. 6) Is Child 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here.

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Medi-Cal Household Parent 1 Child 1 Family Size Parent 1 Included Not Included 1 Child 1 Not Included Included 1

4) Homeless Youth (under 21 years old) The household composition for a homeless youth residing outside the home of their parent(s) and requesting Medi-Cal coverage will vary depending on if the child will be claimed as a tax dependent. Detailed below is guidance on how to evaluate homeless youth with various tax filing statuses. • Homeless youth claimed as a tax dependent: If the homeless youth is claimed as a tax dependent, the county shall follow the Tax Dependent Rules outlined in the “MAGI Household Composition and Tax Filing Rules” section above when determining eligibility. If the homeless youth is unable to provide their parent(s) tax and income information, the CEW shall evaluate the child for Non-MAGI Medi-Cal and the child’s parent(s) may be excluded in the Medi-Cal determination pursuant to Title 22, C.C.R. Sections 50373 and 50381. • Homeless youth not claimed as a tax dependent: If the homeless youth is not claimed as a tax dependent by a parent, or they are unsure of their parents expected filing status, the Non-Filer Rules are used to determine household composition and MAGI Medi-Cal eligibility. As a result, the child’s parent(s) would not be included in the household composition. (42 C.F.R. Section 435.603(h)(3)).

Homeless Youth Example: Homeless Youth (Age 17) is not living with parents and unsure whether they are claimed as a tax dependent.

Homeless Youth’s Household Composition: 1) Does the child expect to file a federal tax return? No. 2) Does the child expect be claimed as a tax dependent by another tax filer? Unsure/Don’t Know 3) Individual 1 qualifies for Non-Filer Rules: Household consists of homeless youth and any of the following living with the homeless youth: the homeless youth’s spouse, the homeless youth’s children (natural, adopted, or step) and the homeless youths parents (natural, adopted, or step). (Household comprised of Homeless Youth Only) 4) Are they married? No. 5) Are they pregnant? No.

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6) Is anyone included in the household pregnant? No. 7) No additional change, end household composition determination here. Medi-Cal Household Parent Child Family Size Homeless Youth Not Included Included 1

Note: For Covered California program eligibility, the tax household size cannot be determined. Individuals must attest to be planning to file a tax return in order to be eligible for financial assistance through Covered California.

5) Separated Spouses Married couples who self-attest to planning to file taxes as “Married Filing Jointly,” regardless of whether they are living together in the same home, are required to include both spouses at application, redetermination or change in circumstance when requesting MAGI Medi-Cal coverage (42 C.F.R 435.603(f)(1)). If an individual self- attests to filing taxes as “Married Filing Jointly” and fails to include their spouse on the case the CEW shall deny or discontinue the entire case for failure to complete the determination or redetermination.

The only instance when the CEW shall not deny or discontinue the entire case is when the individual who the applicant/beneficiary files “Married Filing Jointly” with would have no impact on the household composition and whose income counts. For example, if an individual listed as “Married Filing Jointly” resides out of the home and is not a spouse of any of the household members or an unmarried couple are living together, are filing as “Married Filing Jointly,” but have no mutual tax dependents or children under 21. As outlined in ACWDL 15-26, the CEW shall provide specific information the individual failed to provide on the Notice of Action (NOA). When a case is denied or discontinued for this reason, the following snippet shall be included on the NOA to meet this mandate: “You did not provide the information that we asked for. We need you to provide information about all household members living in your home or included on your tax return to see if you can still get Medi-Cal. Please call us or visit your county social services office to give us this information.”

When using the snippet language above, counties shall also reference the following citation: California Code Regulations Title 22 § 50175, 50171 and Title 42 Code of Federal Regulations § 435.603.

All County Welfare Directors Letter No.: 20-10 Page 28 April 30, 2020 SAWS shall program this system language at the next viable release. Furthermore, translations for this snippet are at the end of this ACWDL. Translations for this snippet are provided in Appendix A. Once a case is discontinued, the CEW shall follow the guidance provided in ACWDL 19-13 for verifications provided during the 90-day cure period following discontinuance. If the individuals are “Married Filing Jointly” in the current tax year but do not expect to file jointly the next year, CEWs shall consider it a reasonably predictable future change in income and the spouses are not required to be included on the case and in each other’s MAGI household composition. Separated Spouses Filing Jointly Example: A married couple (Spouse 1 and Spouse 2) self-attests to planning to file taxes as Married Filing Jointly but is not living together at the same address. Spouse 1 has requested MAGI Medi-Cal coverage, Spouse 2 has not. Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: household consists of tax payer, and all others the tax payer claims as a dependent (Spouse 1) 4) Is Spouse 1 married? Yes. 5) Is Spouse 1 and Spouse 2 living apart and filing separately? No (Include Spouse 2) 6) Is Spouse 1 pregnant? No 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here. Medi-Cal Household Spouse 1 Spouse 2 Family Size Spouse 1 Included Included 2 Married Individual Who Plans to File Separately in the Future Example: A married couple, (Spouse 1 and Spouse 2), are living apart self-attest to filing taxes as Married Filing Jointly in the current year, but indicate that they will not file jointly in the next year. Spouse 1 is applying for coverage and Spouse 2 is not.

All County Welfare Directors Letter No.: 20-10 Page 29 April 30, 2020 Spouse 1’s Household Composition: 1) Does Spouse 1 expect to file a federal tax return? Yes. 2) Does Spouse 1 expect to be claimed as a tax dependent by another tax filer? No. 3) Spouse 1 qualifies for Tax Filer Rules: household consists of tax payer, and all others the tax payer claims as a dependent (Spouse 1 only) 4) Is Spouse 2 married? Yes. 5) Are the individual and their spouse living apart and filing separately? No- based on reasonably predictable change in income (Do not include Spouse 2). 6) Is Spouse 1 pregnant? No. 7) Is anyone included in the household pregnant? No. 8) No additional change, end household composition determination here. Medi-Cal Household Spouse 1 Spouse 2 Family Size Spouse 1 Included Not Included 1 Note: For Covered California program eligibility, if the individual states that they are legally married and planning to file as “Married Filing Separately”, they will be ineligible for financial assistance through Covered California. Individuals in these scenarios should consult with a tax advisor for any exceptions to the filing status rules. If you have any questions, or if we can provide further information, please contact Eric Sweeney by phone at (916) 345-8065 or by email at eric.sweeney@dhcs.ca.gov. Original Signed By Sandra Williams, Chief Medi-Cal Eligibility Division

Page 1 of 3 Language: Translation: English “You did not provide the information that we asked for. We need you to provide information about all household members living in your home or included on your tax return to see if you can still get Medi-Cal. Please call us or visit your county social services office to give us this information.” Spanish “Usted no nos dio la información que le pedimos. Necesitamos que usted nos dé la información sobre todos los miembros del hogar que vivan en su casa o que estén incluidos en su declaración de impuestos, para saber si usted todavía puede recibir Medi-Cal. Por favor llámenos o visite la oficina de servicios sociales de su condado para darnos esta información.” Arabic "أنت لم تقدم المعلومات التي طلبناها. إننا بحاجة إلى أن تزودنا بمعلومات حول جميع أفراد األسرة الذين يعيشون . رجاء االتصال Medi-Cal في منزلك أو المدرجين في إقرارك الضريبي لنرى أنه ما زال يمكنك الحصول على بنا أو زيارة مكتب الخدمات االجتماعية في مقاطعتكم لتزويدنا بهذه المعلومات." Armenian «Դուք չեք տրամադրել այն տեղեկությունը, որը մենք խնդրել էինք։ Մեզ անհրաժեշտ է, որ Դուք մեզ տեղեկություններ տրամադրեք Ձեր ընտանիքի բոլոր այն անդամների մասին, որոնք ապրում են Ձեր տանը կամ նշված են Ձեր հարկագրի մեջ, որպեսզի պարզենք, թե արդյոք Դուք դեռ կարող եք «Medi-Cal» ստանալ։ Խնդրում ենք զանգահարել մեզ կամ այցելել Ձեր շրջանի սոցիալական ծառայությունների գրասենյակ և տրամադրել մեզ այդ տեղեկությունները։» Cambodian “អ្នកមិនបានផ្តល់ព័ត៌មានដែលយ ើងបានយ្នើ្ ុំយន ោះយេ។ យ ើងតម្មូវឲ្យអ្នកផ្តល់ព័ត៌មានអ្ុំពី ្មាជិកម្រួ្ារេាុំងអ្្់ដែលកុំព ងរ្់យនៅកនុងផ្ទោះរប្់អ្នក ឬ្មាជិកដែលបានរួមបញ្ចូល យេៅកនុងលិខិតម្បកា្បង់ពនធ យែើមបីពិនិតយយមើលថាយតើអ្នកអ្ាចបនតេេួលបាន Medi-Cal ដែរឬយេ។ ្ូម េូរ្ពទមកយ ើងខ្ុំ ឬចូលយេៅកាន់ការិ ាល័ យ្វា្ងគមម្បចាុំយខ នធីរប្់អ្នក យែើមបីផ្តល់ឲ្យយ ើងនូវ ព័ត៌មានយនោះ។” Chinese 「您未提供我們要求的資料。我們需要您提供有關居住在您家中或列入納稅申報 表的所有家庭成員的資料，以確認您是否還能獲得 Medi-Cal。請致電我們或前往您所在郡福利處向我們提供此資料。」 Farsi "شما اطالعاتی که ما درخواست کرده بوديم را ارائه نداديد. جهت تعيين اينکه آيا کماکان می توانيد از برخوردار شويد، از شما می خواهيم تا در خصوص تمامی اعضاء خانواده که در خانه شما زندگی Medi-Cal می کنند يا در اوراق مالياتی شما به حساب آورده شده اند، به ما اطالعات ارائه نماييد. برای دادن اين اطالعات لطفا با ما از طريق تلفن تماس بگيريد يا به دفتر خدمات اجتماعی کانتی تان مراجعه نماييد." ً Hmong "Koj tsis muab cov ntaub ntawv uas peb tau thov. Peb xav kom koj muab ntaub ntawv hais txog txhua tus neeg hauv yim neeg uas nyob hauv koj lub tsev los sis suav nrog koj cov se ua kom pom tau yog hais tias koj tseem tuaj yeem tau txais Medi-Cal. Thov hu rau peb los sis mus ntsib koj lub chaw pab cuam pej xeem hauv cheeb nroog kom muab cov ntaub ntawv no rau peb. " Korean "저희가 요청한 정보를 귀하가 제공하지 않았습니다. 귀하가 Medi-Cal 을 계속 받을 수 있는지 확인하려면 귀하의 집에 거주하거나 세금 신고서에 포함된 모든 가구 구성원에 대한 정보를 저희에게제공해야 합니다. 저희에게 이 정보를 제공하려면 저희에게 전화하거나 또는 지역 사회 복지 사무소를 방문하십시오."

Appendix A

Page 2 of 3 Russian "Вы не предоставили запрошенную нами информацию. Нам необходимо, чтобы Вы предоставили информацию обо всех членах семьи, проживающих в Вашем доме или включенных в Вашу налоговую декларацию, чтобы узнать, можете ли Вы по-прежнему получать Medi-Cal. Пожалуйста, позвоните нам или посетите Ваш окружной офис по вопросам социального обеспечения, чтобы предоставить нам эту информацию." Tagalong "Hindi mo ibinigay ang impormasyong hiningi namin. Hinihiling naming ibigay mo ang impormasyon tungkol sa lahat ng miyembro ng sambahayan na nakatira sa iyong bahay o kabilang sa iyong tax return para makita kung maaari ka pa ring makakuha ng Medi-Cal. Pakitawagan kami o bumisita sa tanggapan ng mga serbisyong panlipunan sa iyong county upang ibigay sa amin ang impormasyong ito." Vietnamese “Quý vị đã không cung cấp thông tin chúng tôi yêu cầu. Chúng tôi cần quý vị cung cấp thông tin về mọi thành viên trong hộ gia đình sinh sống tại nhà quý vị hoặc được bao gồm trong tờ khai thuế để xem liệu quý vị vẫn có thể nhận Medi-Cal. Vui lòng gọi chúng tôi hoặc ghé đến văn phòng dịch vụ xã hội quận để cung cấp thông tin này cho chúng tôi.” Hindi "हमने आपसे जो जानकारी माँगी थी वह आपने हमें नहीं दी। हमें आपसे आपके घर में रहने वाले या आपके टैक्स ररटन में शाममल मकये गए पररवार के सभी सदस्ोीं की जानकारी चामहए तामक यह देख सकें मक आपको अभी भी Medi-Cal ममल सकता है या नहीं। हमें यह जानकारी देने के मलए कृपया हमें कॉल करें या अपने काउींटी के सामामजक सेवा कायानलय जाएाँ।" Japanese 「お客様は、当社が請求した情報を提供していません。Medi-Cal を利用する場 合、一緒に暮らしている家族全員の情報、または所得税に含まれる情報を当社 に提供する必要があります。情報を提供するには、当社に電話するか、お客様 の国の社会福祉担当にお問い合わせください。」 Laotian "ທ່ານບໍ່ໄດ້ໃຫ້ຂໍ້ມູນທ ີ່ພວກເຮົາຂໍເອົາ. ພວກເຮົາຕ້ອງການໃຫ້ທ່ານສະໜອງຂໍ້ມູນກ່ຽວກັບສະມາຊິກຄົວເຮືອນທັງໝົດທ ີ່ອາໄສຢູ່ໃນເຮືອນຂອງທ່ານ ຫ ື ລວມມ ຢູ່ໃນໃບແຈ້ງເສຍອາກອນຂອງທ່ານ ເພືີ່ອເບິີ່ງວ່າທ່ານຍັງສາມາດໄດ້ຮັບ Medi-Cal ໄດ້ຫ ືບໍ່. ກະລຸນາໂທຫາພວກເຮົາ ຫ ື ເຂົ້າໄປຫ້ອງການການບໍລິການສັງຄົມປະຈຳເຂດປົກຄອງຂອງທ່ານເພືີ່ອໃຫ້ຂໍ້ມູນນ ົ້ແກ່ພວກເຮົາ. " Mien "Meih maiv duqv dorh dungh yie mbuo duqv tov naaic lorx wuov deix waac-fienx daaih bun. Yie mbuo qienx oix zuqc heuc meih dorh waac-fienx gorngv taux yietc zungv huov jaa hmuangv doic dungh caux meih juangc biauv yiem wuov a’fai lemh jienv fungx meih nyei nzouv-zinh nzuonx bun mangc beiv taux meih corc se duqv zipv longc Medi-Cal. Tov daaix luic douc waac daaih buangh taux yie mbuo a’fai bieqc mingh lorx yiem meih nyei nquenc gunv goux domh zuangx mienh nzie-weih gorn liouh dorh naaiv deix waac-fienx daaih bun yie mbuo oc." Punjabi "ਤੁਸ ੀਂ ਉਹ ਜਾਣਕਾਰ ਪ੍ਰਦਾਨ ਨਹ ੀਂ ਕ ਤ ਜਜਹੜ ਅਸ ੀਂ ਤੁਹਾਡੇ ਕੋਲੋਂ ਮੰਗ ਸ . ਅਸ ੀਂ ਚਾਹੁੰਦੇ ਹਾੀਂ ਜਕ ਤੁਸ ੀਂ ਸਾਨ ੰ ਆਪ੍ਣੇ ਘਰ ਜ ਿੱਚ ਰਜਹੰਦੇ ਸਾਰੇ ਘਰੇਲ ਮੈਂਬਰਾੀਂ ਬਾਰੇ ਜਾਣਕਾਰ ਪ੍ਰਦਾਨ ਕਰੋ ਜਾੀਂ ਜਜਹੜੇ ਤੁਹਾਡ ਟੈਕਸ ਜਰਟਰਨ ਜ ਚ ਸਾਮਲ ਹਨ ਜਜਸ ਨਾਲ ਸਾੀਂਨ ੰ ਇਹ ਪ੍ਤਾ ਲਗ ਜਾ ੇ ਕ ਤੁਸ ੀਂ ਅਜੇ Medi-Cal ਪ੍ਰਾਪ੍ਤ ਕਰਨ ਯੋਗ ਹੋ. ਸਾਨ ੰ ਇਹ ਜਾਣਕਾਰ ਦੇਣ ਲਈ ਜਕਰਪ੍ਾ ਕਰਕੇ ਸਾਨ ੰ ਕਾਲ ਕਰਕੇ ਜਾੀਂ ਆਪ੍ਣੇ ਕਾਉੀਂਟ ਸਮਾਜਜਕ ਸੇ ਾ ਾੀਂ ਦੇ ਦਫਤਰ ਜ ਿੱਚ ਜਾਕੇ ਜਾਣਕਾਰ ਪ੍ਰਦਾਨ ਕਰੋ."

Page 3 of 3 Thai Medi-Cal Ukrainian "Ви не надали інформацію, яку ми просили. Нам потрібно, щоб ви надали інформацію про всіх членів домогосподарства, які мешкають у вашому домі або включені до вашої податкової декларації, щоб перевірити чи зможете ви отримати Medi-Cal. Будь ласка, зателефонуйте нам або відвідайте свій місцевий офіс соціальних служб, щоб надати нам цю інформацію."