Solicitation 017-C003095-GH Social Services Agency

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County of Orange

Bid 017-C003095-GH

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Solicitation 017-C003095-GH

Social Services Agency Medi-Cal Walk-In Packets

Bid designation: Public

County of Orange

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Bid 017-C003095-GH Social Services Agency Medi-Cal Walk-In Packets Bid Number

017-C003095-GH

Bid Title

Social Services Agency Medi-Cal Walk-In Packets

Bid Start Date

Apr 6, 2015 2:06:52 PM PDT

Bid End Date

Apr 9, 2015 9:00:00 AM PDT

Question & Answer End Date

Apr 8, 2015 8:00:00 AM PDT

Bid Contact

Gloria C Horton Deputy Purchasing Agent-Buyer I 714-834-6884 [email protected]

Contract Duration

One Time Purchase

Contract Renewal

Not Applicable

Prices Good for

90 days

Standard Disclaimer     The County of Orange is not responsible for and accepts no liability for any technical difficulties or failures that result from conducting business electronically. Bid Comments

THE COUNTY OF ORANGE, COUNTY EXECUTIVE OFFICE (CEO) / PUBLISHING SERVICES DEPARTMENT IS SOLICITING BIDS FOR A ONE-TIME PURCHASE AND DELIVERY CONTRACT FOR PRINTING AND BINDERY OF ONE SOCIAL SERVICES AGENCY PACKET SETS AS FOLLOWS: MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION) DUE DATE: MAY 1, 2015 @ 3:00 PM.

BASIS OF AWARD: ALL OR NONE.

PLEASE SEE ATTACHED PRINTING SPECIFICATIONS (ATTACHMENT A - SCOPE OF WORK) FOR DETAILED PROJECT INFORMATION FOR THE LINE ITEM. ALL QUESTIONS PERTAINING TO THIS INVITATION FOR BID (IFB) MUST BE SUBMITTED THROUGH BIDSYNC; ANY COUNTY RESPONSE RELEVANT TO THIS IFB OTHER THAN THROUGH OR APPROVED BY CEO/PURCHASING DIVISION IS UNAUTHORIZED AND WILL BE CONSIDERED INVALID. ALL BID RESPONSES SHALL BE SUBMITTED THROUGH BIDSYNC AND THE FOLLOWING MUST BE COMPLETED IN ORDER FOR BID TO BE VALID: 1. SIGNATURE PAGE 2. COMPANY PROFILE 3. REFERENCES 4. CHILD SUPPORT ENFORCEMENT WEB FORM 5. BIDSYNC PRICING THE PROJECT MUST BE DELIVERED ON OR BEFORE MAY 1, 2015 @ 3:00 P.M. TO SOCIAL SERVICES AGENCY AT THE ADDRESS LISTED BELOW: COUNTY OF ORANGE SOCIAL SERVICES AGENCY WAREHOUSE 1505 E. WARNER AVE SANTA ANA, CA 92705 REFERENCE:  #1064941 MEDI-CAL WALK-IN APPLICATION PACKET, ENGLISH

PLEASE READ THE COMPLETE BID BEFORE RESPONDING TO THIS BID. THE COUNTY OF ORANGE WILL REQUEST THE WINNING BIDDER TO SIGN A CONTRACT, AGREEING TO THE COUNTY'S GENERAL TERMS AND CONDITIONS. A MODEL COUNTY OF ORANGE CONTRACT IS INCLUDED IN THIS BID. THE CONTRACTOR IS ALSO AGREEING TO PROVIDE THE COUNTY THE PROJECT ON THE DUE DATE AS SPECIFIED ABOVE. THE WINNING CONTRACTORS SHALL PROVIDE ELECTRONIC PROOFS TO THE COUNTY. 4/7/2015 11:51 AM

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THIS BID. THE CONTRACTOR IS ALSO AGREEING TO PROVIDE THE COUNTY THE PROJECT ON THE DUE DATE AS County of Orange Bid 017-C003095-GH SPECIFIED ABOVE. THE WINNING CONTRACTORS SHALL PROVIDE ELECTRONIC PROOFS TO THE COUNTY.

Item Response Form

Item

017-C003095-GH--01-01 - MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION)

Quantity

14800 set

Unit Price    Delivery Location          County of Orange 026 - SSA/FORMS WAREHOUSE (26)   1505 E WARNER   G101   SANTA ANA CA  92705 Qty 14800 Description MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION) 6

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Signature Page I have read and understand and agree to the terms and conditions herewith and I am submitting a response to this solicitation . Date:

Company Name:

* Authorized Signature

Print Name

Title

* Authorized Signature

Print Name

Title

OR

I prefer not to submit a bid in response to this solicitation per the reason(s) given below. Reason(s):

aaa

Date:

Company Name:

* Authorized Signature

Print Name

Title

* If the Contractor is a corporation, signatures of two specific corporate officers are required as further set forth. The first corporate officer signature must be one of the following:1) the Chairman of the Board; 2) the President; 3) any Vice President. The second corporate officer signature must be one of the following: a) Secretary; b) Assistant Secretary; c) Chief Financial Officer; d) Assistant Treasurer. In the alternative, a single corporate signature is acceptable when accompanied by a corporate resolution demonstrating the legal authority of the signature to bind the company.

RETURN THIS SHEET WITH YOUR RESPONSE

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BIDDER INSTRUCTIONS SECTION 1 – GENERAL INFORMATION I. IMPORTANT NOTICES 1. Bids must be responded to via the BidSync website (www.bidsync.com) by the closing date and time indicated on this solicitation. NO LATE BIDS WILL BE ACCEPTED REGARDLESS OF THE REASON. 2. All changes or modifications to this solicitation will be issued in writing and posted to the BidSync website. 3. Any questions or requests for interpretations or clarifications shall be requested in writing via BidSync (www.bidsync.com) by the question and answer end date as noted on page 2 of this bid. Questions or requests for interpretations/clarifications submitted via email, telephone or fax to the DPA will not be answered. If clarification or interpretation of the IFB is considered necessary, a written addendum shall be issued. Oral statement(s) concerning the meaning of the contents of this IFB by any person is unauthorized and invalid. All other inquiries concerning this IFB should be submitted by e-mail to the Buyer in charge at [email protected]. 4. The County of Orange does not guarantee that you will receive addenda (additonal information, changes or modifications) to this solicitation by email prior to the close of this solicitation or at all. It is the bidder’s responsibility to ensure that they have received all addenda prior to the submission of its bid. 5. CEO/IT regular business hours are 8:00 a.m. to 5:00 p.m.(Pacific Time), Monday through Friday. 6. The County of Orange does not require and neither encourages nor discourages the use of lobbyists or other consultants for the purpose of securing business. II. INSTRUCTIONS – GENERAL 1. If you choose not to submit a bid or “No Bid,” please complete the appropriate section on the cover sheet of the IFB. Please ensure that you have signed the sheet, entered the date, name of your company and the name and title of the person authorized to sign on behalf of the company. Returning a “NO BID” response by the bid due date and time will keep your firm in the system. If you choose to “NO BID” this IFB, please complete the appropriate section on the cover sheet of the IFB, indicating the reason(s) why you have chosen not to bid. A failure to respond to this solicitation may eliminate your firm from the County Purchasing system. 2. Responsive bids will include the following completed pages: 1) Signature page, 2) Company profile, 3) References, 4) Child Support Enforcement Web Form and 5) Bidsync Pricing. The cover sheet of a responsive bid must be signed appropriately and completed with the date and company name. If the bidder is a corporation, then it must contain signatures, name and title of two corporate officers authorized to sign on behalf of the Company. The first signature must be either: 1) the chairman of the board; 2) president; or 3) any vice president. The second signature must be either: 1) the secretary; 2) an assistant secretary; 3) the chief financial officer; or 4) any assistant treasurer. In the alternative, a single corporate signature is acceptable when accompanied by a corporate document demonstrating the legal authority of the signature to bind the company. Completed pages must be scanned and attached as a document to your bid response via bidsync. No other form of bid response will be accepted. BIDDER INSTRUCTIONS 4/7/2015 11:51 AM

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3. Out of state Contractors must include California sales tax permit number. 4. Contractors shall take all responsibility for any errors or omissions in their bids. Any discrepancies in numbers or calculations shall be interpreted to reflect the lowest price to the County of Orange. 5. The County shall not be liable for any expenses incurred by potential Contractors in the preparation or submission of their bids. Pre-contractual expenses are not to be included in your bid. Pre-contractual expenses are defined as including but not limited to, expenses incurred by the bidder in: a) preparing its bid in response to this IFB; b) postage/shipping; c) negotiating with the County any matter related to the bid; d) any other expenses incurred by the bidder prior to the date of award and execution, if any.

III. INSTRUCTIONS - PROTEST PROCEDURES Protest of Bid/Proposal Specifications: All protests related to bid or proposal specifications must be submitted to the Deputy Purchasing Agent no later than five (5) business days prior to the close of the bid or proposal. Protests received after the five (5) business day deadline will not be considered by the County. In the event the protest of specifications is denied and the protester wishes to continue in the solicitation process, they must still submit a bid prior to the close of the solicitation in accordance with the bid/proposal submittal procedures provided in the bid/proposal. Protest of Award of Contract: In protests related to the award of a contract, the protest must be submitted no later than five (5) business days after the notice of the proposed contract award is provided by the Deputy Purchasing Agent. Protests relating to a proposed contract award which are received after the five (5) business day deadline will not be considered by the County. Procedure All protests shall be type-written on the protester’s letterhead and be submitted in accordance with the provisions stated herein. All protests shall include at minimum the following information: The name, address and telephone number of the protester; The signature of the protester or the protester’s representative; The solicitation or contract number; A detailed statement of the legal and/or factual grounds for the protest; and The form of relief requested. Protest Process In the event of a timely protest, the County shall not proceed with the solicitation or award of the contract until the Deputy Purchasing Agent, the County Purchasing Agent or the Procurement Appeals Board renders a decision on the protest. Upon receipt of a timely protest, the Deputy Purchasing Agent will within ten (10) business days of the receipt of the protest, issue a decision in writing which shall state the reasons for the actions taken. BIDDER INSTRUCTIONS 4/7/2015 11:51 AM

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The County may, after providing written justification to be included in the procurement file, make the determination that the award of the contract, without delay, is necessary to protect the substantial interests of the County. The award of a contract shall in no way compromise the protester’s right to the protest procedures outlined herein. If the protester disagrees with the decision of the Deputy Purchasing Agent, the protestor may submit a written notice to the Office of the County Purchasing Agent requesting an appeal to the Procurement Appeals Board, in accordance with the process stated below. Appeal Process If the protester wishes to appeal the decision of the Deputy Purchasing Agent, the protester must submit, within three (3) business days from receipt of letter, a written appeal to the Office of the County Purchasing Agent. Within fifteen (15) business days, the County Purchasing Agent will review all materials in connection with the grievance, assess the merits of the protest and provide a written determination with a decision as to whether the protest shall be forwarded to the Procurement Appeals Board as described in Section 1.4 of this manual. The decision of the County Purchasing Agent will be final and there shall be no right to further administrative appeals. IV. RIGHTS RESERVED TO COUNTY 1. The County, at its sole discretion, reserves the right to accept or reject in whole or in part any or all bids received as a result of this solicitation. 2. The County may cancel this Invitation for Bids in whole or in part without prior notice. Thereafter, the County may issue a solicitation for new bids. 3. Final award determination will be based on the overall lowest responsive, responsible bid, but is contingent upon agency/department approval, which will include a review of the bidders qualifications and references. 4. The County makes no guarantee as to the usage of the services by the County. The County furthermore makes no representation that any Contract will be awarded to any bidder responding to this Invitation For Bid. 5. All bids received will be public record after opening. Proposals/bids are not to be marked as confidential or proprietary. Proposals/bids submitted in response to this IFB are subject to public disclosure. The County shall not be liable for disclosure of any information or records related to this procurement. Additionally, all proposals/bids shall become the property of the County. The County reserves the right to make use of any information or ideas in the proposals/bids submitted. 6. When more than one line item is specified in a solicitation, the County of Orange reserves the right to determine the lowest responsive and responsible bidder on the basis of individual items, groups of items, or all items included in the solicitation, unless otherwise expressly provided for in the solicitation. The County may accept any item or group of items included in the bid unless the bidder expressly objects in its response to the solicitation and conditions its response on the County purchasing all items for which the bidder provided bids. In the event that the bidder so objects, the County may consider the bidder’s objection non-responsive and may render the bidder ineligible for award. 7. The County reserves the right to award its total requirements to one bidder or to apportion those BIDDER INSTRUCTIONS 4/7/2015 11:51 AM

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requirement among two or more bidders as the County may deem to be in the best interests. In addition, negotiations may or may not be conducted with bidder; therefore, the proposal/bid submitted should contain the bidder’s most favorable terms and conditions, since the selection and award may be made without discussion with any bidder. 8. The County reserves the right to waive, at its discretion, any irregularity or informality which the County deems correctable or otherwise not warranting rejection of the bid. 9. The lowest responsive and responsible bid may be subject to further negotiations. 10. By participating in this solicitation, bidders agree to accept the decision of the County Purchasing Agent as final. V. SPECIAL REQUIREMENTS 1. Bidders may be required to present satisfactory evidence that they have been reqularly engaged in the business of providing goods/services required by this solicitation or are reasonably familiar therewith and that they are fully prepared with the necessary capital, material, and machinery as may be required or specified in this solicitation to complete the work to be contracted to the satisfaction of the County. 2. By submitting a bid, the bidder represents that it has thoroughly examined and become familiar with the goods/services required under this Invitation For Bid and that it is capable of providing the goods/services to achieve the County’s objectives. 3. Bidders may be required to provide information regarding and/or proof of the number of years they have provided the goods/services requested in this solicitation. 4. Each bidder must submit its bid in strict accordance with all requirements of this Invitation For Bid. VI. EXCEPTIONS Any exceptions to the County‘s terms and conditions must be clearly stated in responses to this solicitation under a separate section entitled “Exceptions.” Any exception must include the details of the exception and the reasons for it. The County reserves the right to disqualify vendors taking exception to its terms and conditions. Vendors taking exception after notice of award will be disqualified from award of contract. VII. AWARD Final award determination will be based primarily on the overall lowest responsive, responsible bid, but is contingent upon agency/department approval, which will include a review of bidders’ qualifications and references.

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Part 2: Company Profile (Complete this form and submit as Part 2 in second tabbed section of response)

Company Legal Name:

Business Address:

Address for mailed funds:

Telephone Number: (

)

Facsimile Number: (

)

Email Address:

Length of time the firm has been in business:

Length of time at current location:

Is your firm a sole proprietor doing business under a different name:

Yes

No

If yes, please indicate sole proprietor's name and the name you are doing business under:

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Federal Taxpayer ID Number

Is your firm incorporated:

Yes

No

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State of Incorporation:

Regular business hours:

Regular holidays and hours when business is closed:

Contact person in reference to this request for RFP solicitation:

Telephone Number: (

)

Facsimile Number: (

)

Email Address:

Name of administrator to who questions regarding accounts payable should be directed:

Telephone Number: (

)

Facsimile Number: (

)

Email Address:

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EXHIBIT B References All Bidders must provide a minimum of three (3) Letters of Reference. The references should be from clients who are comparable in scope to the County of Orange. Include one reference from a governmental agency. References must cover services performed by your company in the past five (5) years. At least one of the references must cover services performed in the past year. Services should be similar to those services required in this solicitation. Additionally, please complete the form below on the clients who have provided references: References must include the name and address of the company or governmental agency and the name and telephone and facsimile numbers of contact person(s), annual agreement dollar amount of the Contract, and a brief description of the agreement/Contract work and services provided. Attach additional sheets if necessary.

1.

Name of Reference: Address: Contact Name:

Telephone Number:

Annual agreement dollar amount: Facsimile Number: Brief Description of agreement/Contract work or services provided: 5 6

2.

Name of Reference: Address: Contact Name:

Telephone Number:

Annual agreement dollar amount: Facsimile Number: Brief Description of agreement/Contract work or services provided: 5 6

3.

Name of Reference: Address: Contact Name:

Telephone Number:

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ATTACHMENT A SCOPE OF WORK I.

THIS IS A ONE-TIME PURCHASE FOR THE PRINTING AND DELIVERY OF ONE SOCIAL SERVICES AGENCY MEDI-CAL WALK-IN APPLICATION PACKETS AS LISTED: A. MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION) – 14,800 SETS THE REQUIRED DELIVERY DATE OF THE 14,800 SETS ARE DUE ON OR BEFORE MAY 1, 2015 @ 3:00 P.M.

II.

THE PROJECT MUST BE DELIVERED TO SOCIAL SERVICES AGENCY WAREHOUSE AS INSTRUCTED IN THIS SCOPE OF WORK AT THE ADDRESS LISTED BELOW: COUNTY OF ORANGE SOCIAL SERVICES AGENCY WAREHOUSE 1505 E. WARNER AVE. SANTA ANA, CA 92705 REFERENCE: SSA MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION, P1064941)

III. COUNTY PROJECT CONTACT: COUNTY OF ORANGE-PUBLISHING SERVICES JEFF FARKAS 1300 S. GRAND AVE. BLDG. A; 1ST FLOOR SANTA ANA, CA. 92705 PHONE: 714-567-7338 FAX: 714-567-7449 EMAIL: [email protected] COUNTY PURCHASING CONTACT: CONTY OF ORANGE-CEO/IT PURCHASING GLORIA HORTON 1501 E. ST. ANDREW PL., SUITE 200 SANTA ANA, CA 92705 PHONE: 714- 834-6884 FAX: 714-560-4524 EMAIL: [email protected] IV. CONTRACTOR INFORMATION:

TBD

V. DETAILED DESCRIPTION OF WORK TO BE PERFORMED BY CONTRACTOR AS LISTED UNDER THE PRINTING SPECIFICATION ATTACHMENT AND ALSO IN THIS SCOPE OF WORK:

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1.

DIGITAL FILES ARE AVAILABLE FOR THE PROJECT. PLEASE REVIEW FOR MORE INFORMATION ON PRINTING DETAILS.

2.

CONTRACTOR SHALL BE REPONSIBLE FOR THE PICK-UP OF VOTER FORMS AND BOX LABELS FROM PUBLISHING SERVICES ADDRESS.

3.

CONTRACTOR WILL BE PROVIDED WITH SPECIAL BOX LABELS FOR EACH PRINTING PROJECT.

4.

NO UNDERRUNS ALLOWED.

5.

OVERRUNS WILL BE PAID IF APPROVED BY THE COUNTY PUBLISHING MANAGER AND COUNTY OF ORANGE BUYER IS NOTIFIED BY COUNTY PUBLISHING MANAGER.

6.

COUNTY MUST RECEIVE THE MEDI-CAL WALK-IN APPLICATION PACKETS BY OR BEFORE MAY 1, 2015, 3:00 P.M. (PST).

7.

ANY CHANGES OR CORRECTIONS MUST BE VERIFIED IN WRITING TO CONTRACTOR BY PURCHASING.

CONTRACTOR IS REQUIRED TO RETURN PRODUCED OR PROVIDED ARTWORK WITH REVISION TO DEPARTMENT WITH COMPLETED JOB. CEO/IT REGULAR BUSINESS HOURS ARE 8:00 A.M. TO 5:00 P.M. (PST), MONDAY THROUGH FRIDAY.

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ATTACHMENT B COMPENSATION AND PRICING PROVISIONS This is a fixed fee Contract between the County and Contractor for goods and services provided in Attachment A, Scope of Work. The Contractor agrees to accept the specified compensation as set forth in this Contract as full remuneration for services. 1. Pricing Pricing set forth in this Attachment shall be firm for the term of the Contract. All price decreases will automatically be extended to the County of Orange. County will accept a decrease only. Pricing below will be firm unless a reduction is available. Description

Qty.

Unit

Unit Price

Total Price

SSA MEDI-CAL WALK-IN APPLICATION PACKETS (ENGLISH VERSION)

14,800

Sets

$______

$_______

Subtotal (Price includes shipping)

$ _______

Sales Tax (.08%) Total Amount Due

$ _______ $ _______

2. Payment Terms Contractor shall reference Contract number on invoice. Payment will be net 30 days after receipt of an invoice in a format acceptable to the County of Orange and verified and approved by the agency/department and subject to routine processing requirement. The responsibility for providing an acceptable invoice rests with Contractor. Billing shall cover services and/or goods not previously invoiced. The Contractor shall reimburse the County of Orange for any monies paid to the Contractor for goods or services not provided or when goods or services do not meet the Contract requirements. Payments made by the County shall not preclude the right of the County from thereafter disputing any items or services. 3. Invoicing Instructions: Invoices and support documentation are to be sent to: County of Orange CEO/Information Technology 1501 E. St. Andrew Place, Suite 200 Santa Ana, CA 92705 Attn: Accounts Payable Contractor will provide an invoice for services rendered, not more frequently than annually. Each invoice will have a number and shall include the following information: 1. 2. 3. 4. 5. 6. 7. 8.

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Contractor’s name and address Contractor’s remittance address County Contract number Contractor’s Federal I.D. number Date of Order Product/service description, quantity, prices Sales tax, If applicable Total invoice amount

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CONTRACT #XX-XXX-XXXXXXXX FOR XXXXXXXXXX XXXXXXXXXX

This Contract is made and entered into as of the date fully executed by and between xxxxxxxxxx with a place of business at xxxxxxxxxxxxxxxxxxx (hereinafter referred to as “Contractor”), and the County of Orange, a political subdivision of the State of California, (hereinafter referred to as “County”) which may be referred to individually as “Party” or collectively as “Parties”, is established to provide xxxxxxxxxx xxxxxxxxxx.

RECITALS WHEREAS, Contractor responded to the County’s Invitation for Bid (IFB # xxx-xxxxxx-xx), to provide xxxxxxxxxx xxxxxxxxxx, as further set forth herein; and WHEREAS, Contractor responded and represented that its proposed products and services shall meet or exceed the requirements and specifications of IFB # xxx-xxxxxx-xx; and WHEREAS, the County wishes to enter into a Contract to obtain xxxxxxxxxx xxxxxxxxxx; NOW, THEREFORE, the Parties mutually agree as follows:

ARTICLES General Terms and Conditions A. Governing Law and Venue: This Contract has been negotiated and executed in the state of California and shall be governed by and construed under the laws of the state of California. In the event of any legal action to enforce or interpret this Contract, the sole and exclusive venue shall be a court of competent jurisdiction located in Orange County, California, and the Parties hereto agree to and do hereby submit to the jurisdiction of such court, notwithstanding Code of Civil Procedure section 394. Furthermore, the Parties specifically agree to waive any and all rights to request that an action be transferred for trial to another County. B. Entire Contract: This Contract, its Attachments, and Exhibits which have been incorporated, when accepted by the Contractor either in writing or by the shipment of any article or other commencement of performance hereunder, contains the entire Contract between the Parties with respect to the matters herein and there are no restrictions, promises, warranties or undertakings other than those set forth herein or referred to herein. No exceptions, alternatives, substitutes or revisions are valid or binding on County unless authorized by County in writing. Electronic acceptance of any additional terms, conditions or supplemental Contracts by any County employee or agent, including but not limited to installers of equipment, shall not be valid or binding on County unless accepted in writing by the County’s Purchasing Agent or his designee, hereinafter “Purchasing Agent”. C. Amendments: No alteration or variation of the terms of this Contract shall be valid unless made in writing and signed by the Parties; no oral understanding or agreement not incorporated herein shall be binding on either of the Parties; and no exceptions, alternatives, substitutes or revisions are valid or binding on County unless authorized by County in writing. D. Taxes: This Contract shall include any and all applicable taxes. Contractor certifies all taxes in association to the services and/or products applicable to this Contract are herby outline in Attachment B, Cost/Compensation of this Contract. County shall not be charged or liable for any taxes not outlined in Attachment B, Cost/Compensation of this Contract.

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E

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Delivery: Time of delivery of goods or Services is of the essence in this Contract. County reserves the right to refuse any goods or services and to cancel all or any part of the goods not conforming to applicable specifications, drawings, samples or description, or services that do not conform to the prescribed statement of work. Acceptance of any part of the order for goods shall not bind County to accept future shipments, nor deprive it of the right to return goods already accepted, at Contractor’s expense. Over shipments and under shipments of goods shall be only as agreed to in writing by County. Delivery shall not be deemed to be complete until all goods, or services, have actually been received and accepted in writing by County.

F. Acceptance/Payment: Unless otherwise agreed to in writing by County, acceptance of xxxxxxxxx xxxxxxxxxxxxx shall not be deemed complete unless in writing and until all the goods/services have actually been received, inspected, and tested to the satisfaction of County. G. Warranty: Contractor expressly warrants that the goods/services covered by this Contract are 1) free of liens or encumbrances, 2) merchantable and good for the ordinary purposes for which they are used, and 3) fit for the particular purpose for which they are intended. Acceptance of this order shall constitute an agreement upon Contractor’s part to indemnify, defend and hold County and its indemnities as identified in paragraph “HH” below, and as more fully described in paragraph “HH”, harmless from liability, loss, damage and expense, including reasonable counsel fees, incurred or sustained by County by reason of the failure of the goods/services to conform to such warranties, faulty work performance, negligent or unlawful acts, and non-compliance with any applicable state or federal codes, ordinances, orders, or statutes, including the Occupational Safety and Health Act (OSHA) and the California Industrial Safety Act. Such remedies shall be in addition to any other remedies provided by law. H. Patent/Copyright Materials/Proprietary Infringement: Unless otherwise expressly provided in this Contract, Contractor shall be solely responsible for clearing the right to use any patented or copyrighted materials in the performance of this Contract. Contractor warrants that any software as modified through Services provided hereunder shall not infringe upon or violate any patent, proprietary right, or trade secret right of any third party. Contractor agrees that, in accordance with the more specific requirement contained in paragraph “HH” below, it shall indemnify, defend and hold County and County Indemnitees harmless from any and all such claims and be responsible for payment of all costs, damages, penalties and expenses related to or arising from such claim(s), including, but not limited to, attorney’s fees, costs and expenses. I.

Assignment or Sub-contracting: The terms, covenants, and conditions contained herein shall apply to and bind the heirs, successors, executors, administrators and assigns of the Parties. Furthermore, neither the performance of this Contract nor any portion thereof may be assigned or sub-contracted by Contractor without the express written consent of County. Any attempt by Contractor to assign or sub-contract the performance or any portion thereof of this Contract without the express written consent of County shall be invalid and shall constitute a breach of this Contract.

J. Non-Discrimination: In the performance of this Contract, Contractor agrees that it shall comply with the requirements of Section 1735 of the California Labor Code and not engage nor permit any subcontractors to engage in discrimination in employment of persons because of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, or sex of such persons. Contractor acknowledges that a violation of this provision shall subject Contractor to all the penalties imposed for a violation of anti-discrimination law or regulation including but not limited to Section 1720 et seq. of the California Labor Code. K. Termination: In addition to any other remedies or rights it may have by law and those set forth in the Contract, County has the right to terminate this Contract without penalty immediately with cause or after 30 days’ written notice without cause, unless otherwise specified. Cause shall be defined as any breach of Contract, any misrepresentation or fraud on the part of the Contractor. Exercise by County of its right to terminate the Contract shall relieve County of all further obligations.

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

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County of Orange

Bid 017-C003095-GH

L. Consent to Breach Not Waiver: No term or provision of this Contractor shall be deemed waived and no breach excused, unless such waiver or consent shall be in writing and signed by the Party claimed to have waived or consented. Any consent by any Party to, or waiver of, a breach by the other, whether express or implied, shall not constitute consent to, waiver of, or excuse for any other different or subsequent breach. M. Remedies Not Exclusive: The remedies for breach set forth in this Contract are cumulative as to one another and as to any other provided by law, rather than exclusive; and the expression of certain remedies in this Contract does not preclude resort by either Party to any other remedies provided by law. N. Independent Contractor: Contractor shall be considered an independent Contractor and neither Contractor, its employees nor anyone working under Contractor shall be considered an agent or an employee of County. Neither Contractor, its employees nor anyone working under Contractor, shall qualify for workers’ compensation or other fringe benefits of any kind through County. O. Performance: Contractor shall perform all work under this Contract, taking necessary steps and precautions to perform the work to County’s satisfaction. Contractor shall be responsible for the professional quality, technical assurance, timely completion and coordination of all documentation and other goods/services furnished by the Contractor under this Contract. Contractor shall perform all work diligently, carefully, and in a good and workman-like manner; shall furnish all labor, supervision, machinery, equipment, materials, and supplies necessary therefore; shall at its sole expense obtain and maintain all permits and licenses required by public authorities, including those of County required in its governmental capacity, in connection with performance of the work; and, if permitted to subcontract, shall be fully responsible for all work performed by subcontractors. P. Bills and Liens: Contractor shall pay promptly all indebtedness for labor, materials and equipment used in performance of the work. Contractor shall not permit any lien or charge to attach to the work or the premises, but if any does so attach, Contractor shall promptly procure its release and, in accordance with the requirements of paragraph “HH” below, indemnify, defend, and hold County harmless and be responsible for payment of all costs, damages, penalties and expenses related to or arising from or related thereto. Q. Changes: Contractor shall make no changes in the work or perform any additional work without the County’s specific written approval. R. Change of Ownership: Contractor agrees that if there is a change or transfer in ownership of Contractor’s business prior to completion of this Contract, the new owners shall be required under terms of sale or other transfer to assume Contractor’s duties and obligations contained in this Contract and complete them to the satisfaction of County. S. Force Majeure: Contractor shall not be assessed with liquidated damages or unsatisfactory performance penalties during any delay beyond the time named for the performance of this Contract caused by any act of God, war, civil disorder, employment strike or other cause beyond its reasonable control, provided Contractor gives written notice of the cause of the delay to County within 36 (thirty-six) hours of the start of the delay and Contractor avails himself of any available remedies. T. Confidentiality: Contractor agrees to maintain the confidentiality of all County and County-related records and information pursuant to all statutory laws relating to privacy and confidentiality that currently exist or exist at any time during the term of this Contract. All such records and information shall be considered confidential and kept confidential by Contractor and Contractor’s staff, agents and employees. U. Compliance with Laws: Contractor represents and warrants that services to be provided under this Contract shall fully comply, at Contractor’s expense, with all standards, laws, statutes, restrictions, ordinances, requirements, and regulations (collectively “laws”), including, but not limited to those issued by County in its governmental capacity and all other laws applicable to the services at the time services are provided to and accepted by County. Contractor acknowledges that County is relying on Contractor to (Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 3 of 12 p. 19

County of Orange

Bid 017-C003095-GH

ensure such compliance, and pursuant to the requirements of paragraph “HH” below, Contractor agrees that it shall defend, indemnify and hold County and County Indemnitees harmless from all liability, damages, costs and expenses arising from or related to a violation of such laws. V. Freight (F.O.B. Destination): Contractor assumes full responsibility for all transportation, transportation scheduling, packing, handling, insurance, and other services associated with delivery of all products deemed necessary under this Contract. W. Pricing: The Contract price shall include full compensation for providing all required goods in accordance with required specifications, or services as specified herein or when applicable, in the Scope of Work attached to this Contract, and no additional compensation shall be allowed therefore, unless otherwise provided for in this Contract. X. Waiver of Jury Trial: Each Party acknowledges that it is aware of and has had the opportunity to seek advice of counsel of its choice with respect to its rights to trial by jury, and each Party, for itself and its successors, creditors, and assigns, does hereby expressly and knowingly waive and release all such rights to trial by jury in any action, proceeding or counterclaim brought by any Party hereto against the other (and/or against its officers, directors, employees, agents, or subsidiary or affiliated entities) on or with regard to any matters whatsoever arising out of or in any way connected with this Contract and /or any other claim of injury or damage. Y. Terms and Conditions: Contractor acknowledges that it has read and agrees to all terms and conditions included in this Contract. Z. Headings: The various headings and numbers herein, the grouping of provisions of this Contract into separate clauses and paragraphs, and the organization hereof are for the purpose of convenience only and shall not limit or otherwise affect the meaning hereof. AA. Severability: If any term, covenant, condition or provision of this Contract is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions hereof shall remain in full force and effect and shall in no way be affected, impaired or invalidated thereby. BB. Calendar Days: Any reference to the word “day” or “days” herein shall mean calendar day or calendar days, respectively, unless otherwise expressly provided. CC. Attorneys Fees: In any action or proceeding to enforce or interpret any provision of this Contract, or where any provision hereof is validly asserted as a defense, each party shall bear its own attorney’s fees, costs and expenses. DD. Interpretation: This Contract has been negotiated at arm’s length and between persons sophisticated and knowledgeable in the matters dealt with in this Contract. In addition, each Party has been represented by experienced and knowledgeable independent legal counsel of their own choosing, or has knowingly declined to seek such counsel despite being encouraged and given the opportunity to do so. Each Party further acknowledges that they have not been influenced to any extent whatsoever in executing this Contract by any other Party hereto or by any person representing them, or both. Accordingly, any rule of law (including California Civil Code Section 1654) or legal decision that would require interpretation of any ambiguities in this Contract against the Party that has drafted it is not applicable and is waived. The provisions of this Contract shall be interpreted in a reasonable manner to affect the purpose of the Parties and this Contract. EE. Authority: The Parties to this Contract represent and warrant that this Contract has been duly authorized and executed and constitutes the legally binding obligation of their respective organization or entity, enforceable in accordance with its terms. (Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 4 of 12 p. 20

County of Orange

Bid 017-C003095-GH

FF. Employee Eligibility Verification: The Contractor warrants that it fully complies with all Federal and State statutes and regulations regarding the employment of aliens and others and that all its employees performing work under this Contract meet the citizenship or alien status requirement set forth in Federal statutes and regulations. The Contractor shall obtain, from all employees performing work hereunder, all verification and other documentation of employment eligibility status required by Federal or State statutes and regulations including, but not limited to, the Immigration Reform and Control Act of 1986, 8 U.S.C. §1324 et seq., as they currently exist and as they may be hereafter amended. The Contractor shall retain all such documentation for all covered employees for the period prescribed by the law. The Contractor shall indemnify, defend with counsel approved in writing by County, and hold harmless, the County, its agents, officers, and employees from employer sanctions and any other liability which may be assessed against the Contractor or the County or both in connection with any alleged violation of any Federal or State statutes or regulations pertaining to the eligibility for employment of any persons performing work under this Contract. GG. Indemnification Provisions: Contractor agrees to indemnify, defend with counsel approved in writing by County, and hold County, its elected and appointed officials, officers, employees, agents and those special districts and agencies which County’s Board of Supervisors acts as the governing Board (“County Indemnitees”) harmless from any claims, demands or liability of any kind or nature, including but not limited to personal injury or property damage, arising from or related to the services, products or other performance provided by Contractor pursuant to this Contract. If judgment is entered against Contractor and County by a court of competent jurisdiction because of the concurrent active negligence of County or County Indemnitees, Contractor and County agree that liability shall be apportioned as determined by the court. Neither Party shall request a jury apportionment. HH. Audits/Inspections: Contractor agrees to permit the County’s Auditor-Controller or the Auditor-Controller’s authorized representative (including auditors from a private auditing firm hired by the County) access during normal working hours to all books, accounts, records, reports, files, financial records, supporting documentation, including payroll and accounts payable/receivable records, and other papers or property of contractor for the purpose of auditing or inspecting any aspect of performance under this contract. The inspection and/or audit will be confined to those matters connected with the performance of the contract including, but not limited to, the costs of administering the contract. The County will provide reasonable notice of such an audit or inspection. The County reserves the right to audit and verify the contractor’s records before final payment is made. Contractor agrees to maintain such records for possible audit for a minimum of three years after final payment, unless a longer period of records retention is stipulated under this contract or by law. Contractor agrees to allow interviews of any employees or others who might reasonably have information related to such records. Further, contractor agrees to include a similar right to the County to audit records and interview staff of any subcontractor related to performance of this contract. Should the contractor cease to exist as a legal entity, the contractor’s records pertaining to this agreement shall be forwarded to the surviving entity in a merger or acquisition or, in the event of liquidation, to the County’s project manager.

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 5 of 12 p. 21

County of Orange

Bid 017-C003095-GH

SIGNATURE PAGE CONTRACT #XX-XXX-XXXXXXXX FOR XXXXXXXXXX XXXXXXXXXX

In WITNESS WHEREOF, the Parties hereto have executed this Contract on the dates shown opposite their respective signatures below:

* XXXXXXXXXX (This Is A MODEL Contract - DO NOT Sign This Page At This Time) DATE:

________________

SIGNATURE: __________________________________________ PRINT NAME: ________________________________________ TITLE: __________________________________________

* XXXXXXXXXX (This is a MODEL Contract - DO NOT Sign This Page at This Time) DATE:

________________

SIGNATURE: __________________________________________ PRINT NAME: ________________________________________ TITLE: __________________________________________

* If the contracting party is a corporation, (2) two signatures are required as further set forth in this paragraph. The first signature shall be: (a) the Chairman of the Board; b) the President; or c) any Vice President. The second signature shall be a) the Secretary; or 2) any Assistant Secretary; or 3) the Chief Financial Officer; or d) any Assistant Treasurer. In the alternative, a single corporate

signature is acceptable when accompanied by a corporate document demonstrating the legal authority of the signature to bind the company.

COUNTY OF ORANGE A political subdivision of the State of California SIGNATURE: _________________________________ TITLE: ______________________________________ DATE:

____________________________________

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 6 of 12 p. 22

County of Orange

Bid 017-C003095-GH

ATTACHMENT A SCOPE OF WORK CONTRACT #XX-XXX-XXXXXXXX FOR XXXXXXXXXX XXXXXXXXXX

I.

SCOPE Contract is issued by the County of Orange/County Executive Office Information Technology (County CEO/IT) Department to obtain xxxxxxxxxx xxxxxxxxxx.

II.

PRODUCT LISTING

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 7 of 12 p. 23

County of Orange

Bid 017-C003095-GH

ATTACHMENT B COST/COMPENSATION CONTRACT #XX-XXX-XXXXXXXX FOR XXXXXXXXXX XXXXXXXXXX

I.

FIXED-PRICE CONTRACT This is a fixed-priced Contract between County and Contractor for xxxxxxxxxx xxxxxxxxxx as specified in Attachment A, Scope of Work. Contractor agrees to accept the specified compensation as set forth in this Contract as full remuneration for performing all services and furnishing all staffing and materials required.

Contract Monetary Limit: The “not to exceed” monetary limit of this Contract shall be $xxxxxx Any increase to the Contract not to exceed limit shall be mutually agreed to by the County and Contractor, and shall be executed via an Amendment to the Contract. II.

COST/PRICING

Line Item

Product Number

Description

Qty

Unit Price

Extended Price

1

xxxxxx

xxxxxxxxxx xxxxxxxxxx

x

$xx.xx

$xx.xx

2

xxxxxx

xxxxxxxxxx xxxxxxxxxx

x

$xx.xx

$xx.xx

3

xxxxxx

xxxxxxxxxx xxxxxxxxxx

x

$xx.xx

$xx.xx

Subtotal:

$xx.xx

Taxes:

$xx.xx

CONTRACT TOTAL:

$xx.xx

III. COMPENSATION This is a fixed price Contract between the County and the Contractor for xxxxxxxxxx xxxxxxxxxx as further described in this Contract. The Contractor agrees to accept the specified compensation as set forth in this Contract as full remuneration for performing all services and furnishing all staffing and materials required, for any reasonably unforeseen difficulties which may arise or be encountered in the execution of the services until acceptance, for risks connected with the services, and for performance by the Contractor (Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 8 of 12 p. 24

County of Orange

Bid 017-C003095-GH

of all its duties and obligations hereunder. The County shall have no obligation to pay any sum in excess of total Contract amount specified herein unless authorized by amendment. IV. CONTRACT MONETARY LIMIT: The “not to exceed” monetary limit for the term of this Contract shall be $xxxx. Any increase to the Contract not to exceed limit shall be mutually agreed to by the County and Contractor, and shall be executed via an amendment to the Contract. V.

PAYMENT TERMS Contractor shall reference Contract number on all invoices. Payment shall be net 45 days after receipt of an invoice in a format acceptable to the County and verified and approved by the agency/department and subject to routine processing requirements. Payment for services shall be in accordance with the provisions of the Contract. County’s Project Manager shall be responsible for verification and approval of invoices. The responsibility for providing an acceptable invoice to County for payment rests with Contractor. Incomplete or incorrect invoices are not acceptable and shall be returned to Contractor for correction. County’s Project Manager, or designee, is responsible for approval of invoices and subsequent submittal of invoices to the Auditor-Controller for processing of payment. Billing shall cover services and/or goods not previously invoiced. The Contractor shall reimburse the County for any monies paid to the Contractor for goods or services not provided or when goods or services do not meet the Contract requirements. Payments made by County shall not preclude the right of County from thereafter disputing any items or services involved or billed under this Contract and shall not be construed as acceptance of any part of the goods or services.

VI. INVOICING INSTRUCTIONS The Contractor shall provide an invoice on Contractor’s letterhead for services rendered. Each invoice shall have a number and shall include the following information: 1. 2. 3. 4. 5. 6. 7. 8.

Contractor’s name and address Contractor’s remittance address (if different from 1 above) Name of County Agency/Department County Contract Number: #xx-xxx-xxxxxxxx Type of Service Provided Products Provided Contractor’s Federal I. D. number Total Cost

Invoices and support documentation are to be forwarded to: County of Orange – CEO/IT Attn: (County Project Manager NAME) 1400 N. Grand Santa Ana, CA 92705 (Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 9 of 12 p. 25

County of Orange

Bid 017-C003095-GH

EXHIBIT I County of Orange Child Support Enforcement Certification Requirements In order to comply with child support enforcement requirements of the County of Orange, within 10 days of award of Contract, the successful Contractor must furnish to the County Agency/Department deputy purchasing agent: A.

In the case of an individual Contractor, his/her name, date of birth, Social Security number, and residence address;

B.

In the case of a Contractor doing business in a form other than as an individual, the name, date of birth, Social Security number, and residence address of each individual who owns an interest of 10 percent or more in the contracting entity;

C.

A certification that Contractor has fully complied with all applicable federal and state reporting requirements regarding its employees; and

D.

A certification that Contractor has fully complied with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignment and will continue to so comply. The certifications will be stated as follows:

"I certify that __________________ is in full compliance with all applicable federal and state reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number______________ with the County of Orange. I understand that failure to comply shall constitute a material breach of the Contract and that failure to cure such breach within 10 calendar days of notice from County shall constitute grounds for termination of the Contract. It is expressly understood that this data will be transmitted to governmental agencies charged with the establishment and enforcement of child support orders and for no other purposes and will be held confidential by those agencies. Failure of Contractor to timely submit the data and/or certifications required above or to comply with all federal and state reporting requirements for child support enforcement or to comply with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignment shall constitute a material breach of the Contract. Failure to cure such breach within 10 calendar days of notice from County shall constitute grounds for termination of the Contract. After notification of award, the successful Contractor may use the forms supplied herein, to furnish required information listed above.

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 10 of 12 p. 26

County of Orange

Bid 017-C003095-GH

COUNTY OF ORANGE CHILD SUPPORT ENFORCEMENT CERTIFICATION REQUIREMENTS

A.

In the case of an individual Contractor, his/her name, date of birth, Social Security number, and residence address: Name: D.O.B: Social Security No: Residence Address:

B.

In the case of a Contractor doing business in a form other than as an individual, the name, date of birth, Social Security number, and residence address of each individual who owns an interest of 10 percent or more in the contracting entity: Name: D.O.B: Social Security No: Residence Address:

Name: D.O.B: Social Security No: Residence Address:

Name: D.O.B: Social Security No: Residence Address

(Additional sheets may be used if necessary.)

C.

A certification that Contractor has fully complied with all applicable federal and state reporting requirements regarding its employees; and

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 11 of 12 p. 27

County of Orange

D.

Bid 017-C003095-GH

A certification that Contractor has fully complied with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignment and will continue to so comply.

"I certify that ___________________ is in full compliance with all applicable federal and state reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract ________________ with the County of Orange. I understand that failure to comply shall constitute a material breach of the Contract and that failure to cure such breach within 10 calendar days of notice from the County shall constitute grounds for termination of the Contract.

Authorized Signature

Name

Title

(Insert Contractor Name) (Insert Name of Contract) – MODEL Contract 4/7/2015 11:51 AM

Page 12 of 12 p. 28

County of Orange

Bid 017-C003095-GH

5

Attachment I

COUNTY OF ORANGE CHILD SUPPORT ENFORCEMENT CERTIFICATION REQUIREMENTS A.

For an individual contractor: Name, date of birth, social security number, and residence address: Name: D.O.B: Social Security No: 5

Residence Address:

B.

6

For contractor doing business in a form other than as an individual: The name, date of birth, social security number, and residence address of each individual who owns an interest of 10 percent or more in the contracting entity (if no individual owns 10 percent or more, write "N/A"): Name: D.O.B: Social Security No: 5

Residence Address:

6

Name: D.O.B: Social Security No: 5

Residence Address:

6

Name: D.O.B: 4/7/2015 11:51 AM

p. 29

Social Security No:

Name:

County of Orange

Bid 017-C003095-GH

D.O.B: Social Security No: 5 6

Residence Address:

(Additional sheets may be used if necessary)

C.

A certification that the Contractor has fully complied with all applicable federal and state reporting requirements regarding its employees; and

D.

A certification that the Contractor has fully complied with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignment and will continue to so comply

Child Support Enforcement Certificate

"I certify that

is in full compliance with all applicable federal and

state reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of the Agreement

with the County of Orange. I understand that failure

to comply shall constitute a material breach of the Agreement and that failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the Agreement.

Signature*

Name (Please Print)

Title

Date

Signature*

Name (Please Print)

Title

Date

Company Name

Agreement Number 4/7/2015 11:51 AM

p. 30

County of Orange

Agreement Number

Bid 017-C003095-GH

*Two signatures required if a corporation.

6

4/7/2015 11:51 AM

p. 31

County of Orange

Bid 017-C003095-GH

Medi-Cal Walk-in Application Packet (English) Medi-Cal Walk-in Application Packet (English) Forms to Return MC 219 (4/10) Important Information For Persons Requesting Medi-Cal MC 13 (12/09) Statement of Citizenship, Alienage, and Immigration Status (3 COPIES) Notice Regarding Transfer of a Home for Both a DHCS 7077 A Married and an Unmarried Applicant/Beneficiary (Eng/SP) (05/07) NVRA Voter Would You Like To Register To Vote? Preference Form (01/13) California Voter Registration Form

No Form #

Informing Notices Breast and Cervical Cancer Treatment Program (BCCTP)

MC Info Notice 372 (09/09)

Proof of Citizenship and Identity

DHCS 0001 (05/09)

Medi-Cal General Property Limitations

MC Information Notice 007 (01/15)

Your Rights

PUB 13 (06/11)

CalOptima Information

PRI-041-101 (06/08)

WIC Informing Notice

F063-19-96 (02/13)

Medical and Dental Health Check Ups

PUB 183 (English 06/04)

Medi-Cal Services for Children and Young People

MC 003 (11/12)

Language Service Notice

MC 4034 (01/08)

Medi-Cal: What It Means To You

Pub 68 (11/10)

WIC is Helping Families Grow Healthy

DTP 1087

Fee for Service Flyer

F063-19-975 (08/14)

E-Notification Informing Flyer

F063-19-976 (09/14)

Self Service Flyer

F063-19-977 (09/14)

Health Guide for Pregnant Women

No Form #

Medi-Cal Walk-In Cover Letter - English - 04-01-15 Order 4/7/2015 11:51 AM

p. 32

State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

Important Information for Persons Requesting Medi-Cal Privacy and Confidentiality Notification Sections 14011 and 14012 of the Welfare and Institutions Code allow the local social services

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State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

I Have The Right To: continued from page 1

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MC 219 (4/10) p. 34

State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

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State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

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State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

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MC 219 (4/10) English 4/7/2015 11:51 AM

-5p. 37

State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

I Understand That: continued from page 5

16. After my death, the State has the right to seek reimbursement from my estate for all MediCal benefits I received after age 55 unless I have a surviving spouse or registered domestic partner (during his or her lifetime), minor children, blind or permanently and totally disabled children, or it would create a hardship for my heirs.

17. After the death of my surviving spouse or registered domestic partner, the State has the right to claim from the part of his or her estate received from me, all Medi-Cal benefits I received after age 55 up to the amount of property my spouse or registered domestic partner received from my estate.

-64/7/2015 11:51 AM

MC 219 (4/10) p. 38

State of California Health and Human Services Agency

County of Orange

Bid 017-C003095-GH Department of Health Care Services

(Keep for your records) I hereby state that I have reviewed the information on this form with a county representative and that I fully understand my Rights and Resposibilities to have my eligibility determined for Medi-Cal and to maintain that eligibility.

ApplicantL8 tive Signature(opcional)

Date

County Use Section I !')(TIn Person T#

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Eligibility Worker’s Signature

$"B'6L"D(English 4/7/2015 11:51 AM

-7p. 39

State of California—Health and Human Services Agency

County of Orange

Bid 017-C003095-GH

Department of Health Care Services

STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS Print name of applicant (the applicant is the person who want s Medi-Cal)

Date

Print name of person acting for applicant

Relationship to applicant

SECTION A: MEDI-CAL BENEFITS TO CITIZENS AND ALIENS Citizens and nationals of the United States who meet all eligibility requirement s may receive full Medi-Cal benefits. Aliens who meet all eligibility requirements may receive either full Medi-Cal benefits (if they are in a satisfactory immigration status) or restricted benefits limited to emergency and pregnancy-related services (if they are not in a satisfactory immigration st atus). Satisfactory immigration st atus and full Medi-Cal benefit s for aliens: Federal and st ate law provide that full Medi-Cal benefits may be received only by aliens who are in a satisfactory immigration status and who meet all eligibility requirements including California residency. Aliens are in a satisfactory immigration status if they are amnesty aliens with valid and current lawful temporary resident cards (I-688) or lawful permanent residents or permanently residing in the U.S. under color of law (PRUCOL). The 16 PRUCOL categories are listed in SECTION B, question 5 below. Documented aliens not in a satisfactory immigration status who meet all eligibility requirements, including California residency , may receive restricted benefits (limited to emergency and pregnancy-related services). Undocumented aliens who meet all eligibility requirements, including California residency , may receive restricted benefits (limited to emergency and pregnancy-related services). Citizenship/immigration status information: Every person requesting Medi-Cal is required to provide information about his/her citizenship or immigration st atus. Immigration st atus information provided as part of the Medi-Cal application is confidential and cannot be used by the INS for immigration enforcement unless you are committing fraud. Alien status documents and verification requirements: Aliens who claim to be in a satisfactory immigration status (SIS) for Medi-Cal purposes must present INS documents that show their immigration status if they have an INS document or are eligible to obtain one. Aliens who claim to be in an SIS, but who cannot obtain an INS document or replacement receipt (for example, aliens in the last PRUCOL category indicated in SECTION B below) should submit other evidence establishing their immigration status. INS documents will be verified by the INS. Aliens who do not have these documents with them, or who have unreadable documents, may bring us receipts which show that they have applied for replacements. Aliens will have 30 days to do this, or until their Medi-Cal application is ruled on, whichever is longer. If the alien is otherwise eligible, Medi-Cal will be issued during this period and while the submitted documentation is being verified by the INS. If none of the documents contains the applicant's photograph, they must show us an identity document which establishes that the applicant is the person named in the documents. Social Security number requirement: Every person requesting Medi-Cal who has a Social Security number is asked to provide it to the county welfare department. U.S. citizens, U.S. nationals, and aliens claiming to be in a satisfactory immigration status who do not have a Social Security number must apply for one and provide it to the county welfare department. Aliens in satisfactory immigration status for Medi-Cal purposes who need help applying for a Social Security number should ask their eligibility worker for assistance. Aliens who are not in a satisfactory immigration status and who do not have a Social Security number can still get restricted Medi-Cal if they meet all eligibility requirements. SECTION B: CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Is the applicant a citizen or national of the United States?

❒ Yes

❒ No

If the applicant is a citizen or a national of the United States, where was he/she born? _______________________________________ (city, state)

IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE ANSWER QUESTIONS 2, 3, AND 4 BELOW (AND QUESTION 5 IF YOU CLAIM TO BE PRUCOL) THEN COMPLETE SECTIONS C AND D. IF YOU ANSWER "NO" TO QUESTIONS 2, 3, OR 4 BECAUSE THOSE CATEGORIES DO NOT APPLY TO YOU, YOUR ANSWER IS CONFIDENTIAL. THIS INFORMATION CAN ONLY BE USED FOR MEDI-CAL PURPOSES AND CANNOT BE USED BY THE INS FOR IMMIGRATION ENFORCEMENT UNLESS YOU ARE COMMITTING FRAUD. 2. Is the applicant an amnesty alien with a valid and current I-688?

❒ Yes

❒ No

3. Is the applicant a lawful permanent resident?

❒ Yes

❒ No

4. Is the applicant a PRUCOL alien?

❒ Yes

❒ No

IMPORTANT: All PRUCOL aliens must indicate their specific PRUCOL status in question 5. 5. If the applicant would qualify for Medi-Cal benefits as a PRUCOL alien, indicate the status category which entitles him/her to that classification: ❒

A conditional entrant admitted to the United States before April 1, 1980

❒

An alien paroled into the United States, including Cuban/Haitian entrants

MC 13 (12/09)

4/7/2015 11:51 AM

p. 40

County of Orange

Bid 017-C003095-GH

❒

An alien subject to an Order of Supervision

❒

An alien granted an indefinite st ay of deportation

❒

An alien granted an indefinite volunt ary departure

❒

An alien on whose behalf an immediate relative petition (INS Form I-130) has been approved and who is entitled to voluntary departure

❒

An alien who has properly filed an application for lawful permanent resident status

❒

An alien granted a stay of deportation for a specified period

❒

An alien granted asylum

❒

A refugee admitted to the United States since April 1, 1980

❒

An alien granted voluntary departure who is awaiting issuance of a visa

❒

An alien in deferred action status

❒

An alien who entered and has continuously resided in the United States since before January 1, 1972, who would be eligible for an adjustment of status to lawful permanent resident pursuant to INA Section 249 (eligible as a Registry Alien)

❒

An alien granted a suspension of deportation whose departure INS does not contemplate enforcing

❒

An alien granted withholding of deportation pursuant to INA Section 243(h)

❒

An alien, not in one of the above categories, who can show that: (1) INS knows he/she is in the United States; and (2) INS does not intend to deport him/her, either because of the person’ s status category or individual circumstances

SECTION C: VERIFICATION OF IMMIGRATION STATUS (FOR ALIENS WHO CLAIM SATISFACTORY IMMIGRATION STATUS) IMPORTANT: Complete this section only if you answered “yes” to questions 2, 3, or 4 in SECTION B on the front of this form. 1. Alien Registration number and/or Alien Admission number (INS Form I-94):

____________________________________________

2. Date the applicant first entered the United S tates:

____________________________________________

3. Applicant’s name when he/she first entered the United States:

____________________________________________

4. Of what country is the applicant a citizen:

____________________________________________

5. Where was the applicant born:

____________________________________________

SECTION D: SOCIAL SECURITY NUMBER Does the applicant have a Social Security number (SSN)? (Aliens who are not in a satisfactory immigration status, and who do n ot have an SSN, can still get restricted Medi-Cal if they meet all eligibility requirements.) ❒

Yes, the applicant’s Social Security number is:

❒

No

____________________________________________

SECTION E: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. Applicant signature

Date

Signature of person acting for applicant

Date

FOR COUNTY USE ONLY EW number: ________________________________ County: __________________________________ Date:____________________ Action taken: ❒ None necessary. ❒ SAVE primary verification performed. Date: ________________________ ❒ Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Date: ____________________ ❒ Full Medi-Cal benefits were granted pending verification of immigration status. ❒ Copies of alien status documents are in the case file. ❒ Person referred to INS to obt ain replacement documents. Date: ________________________ COUNTY DETERMINATION OF THE APPROPRIATE LEVEL OF MEDI-CAL BENEFITS. Based on the information provided on this form: ❒ The above named applicant is a U.S. citizen or national, or an alien, who, if otherwise eligible, would receive FULL Medi-Cal benefits. ❒ The above named applicant is an alien, who, if otherwise eligible, would receive RESTRICTED Medi-Cal benefits. MC 13 (12/09)

4/7/2015 11:51 AM

p. 41

State of California—Health and Human Services Agency

County of Orange

Bid 017-C003095-GH

DHpartment of Health Care Services

STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS Print name of applicant (the applicant is the person who want s Medi-Cal)

Date

Print name of person acting for applicant

Relationship to applicant

SECTION A: MEDI-CAL BENEFITS TO CITIZENS AND ALIENS Citizens and nationals of the United States who meet all eligibility requirement s may receive full Medi-Cal benefitV. Aliens who meet all eligibility requiremenWV may receive either full Medi-Cal benefiWV (if they are in a satisfactory immigration stDtus) or restricted benefits limited to emergency and pregnancy-related services (if they are not in a satisfactory immigration st atus). Satisfactory immigration st atus and full Medi-Cal benefit s for aliens: Federal and st ate law provide that full Medi-Cal benefits may be received only by aliens who are in a satisfactory immigration status and who meet all eligibility requirements including California residency. Aliens are in a satisfactory immigration stDtus if they are amnesty aliens with valid and current lawful temporary resident caUGV (I-688) or ODZIXOpermanent residenWV or permanently residing in the U.S. under color of law (PRUCOL).7he 16 PRUCOL categories are listed in SECTION B, question 5 below. Documented aliens not in a satisfactory immigration status who meet all eligibility requiremenWV, including California residency , may receive restricted benefits (limited to emergency and pregnancy-related services). Undocumented aliens ZKo meet all eligibility requiremenWV, including California residency , may receive restricted benefiWV (limited to emergency and pregnancy-related services). Citizenship/immigration status information: Every person requesting Medi-Cal is required to provide information about his/her citizenship or immigration st atus. Immigration st atus information provided as SDrt of the Medi-Cal application is confidential and cannot bH used by the INS for immigration enforcement unless you are committing fraud. Alien status documents and verification requirements: Aliens who claim to be in a satisfactory immigration sWDtus (SIS) for Medi-Cal purposes must present INS documentV that show their immigration stDtus if they have an INS document or are eligible to obWDin one. Aliens who claim to be in an SIS, but who cannot obtDin an INS document or replacement receipt (for example, aliens in the last PRUCOL category indicated in SECTION B below) should submit other evidence establishing their immigration status. INS documents will be verified by the INS. Aliens who do not have these documentV with them, or who have unreadable documentV, may bring us receiptV which show that they have applied for replacements. Aliens will have 30 days to do this, or until their Medi-Cal application is ruled on, whichever is lRQger. If the alien is otherwise eligible, Medi-Cal will be issued during this period and while the submitted documentation is being verified by the INS. If none of the documents contains the applicant's photograph, they must show us an identity document which esWDblishes that the applicant is WKe person named in the documents. Social Security number requirement: Every person requesting Medi-Cal who has a Social Security number is asked to provide it to the county welfare department. U.S. citizens, U.S. nationals, and aliens claiming to be in a satisfactory immigration sWDWus who do not have a 6RFLDOSecurity number must apply for one and provide it to the county welfare deSDrtment. Aliens in satisfactory immigration stDtus for 0HGL&DOpurposes who need help applying for a Social Security number should ask their eligibility worker for assisWDnce. Aliens who are QRWLQDsatisfactory immigration sWDtus and who do not have a Social Security number can still get restricted Medi-Cal if they meet all eligibility requirements. SECTION B: CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Is the applicant a citizen or national of the United SWates?

Yes

No

If the applicant is a citizen or a national of the United SWates, where was he/she born? _______________________________________ (city, state)

IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE ANSWER QUESTIONS 2, 3, AND 4 BELOW (AND QUESTION 5 IF YOU CLAIM TO BE PRUCOL) THEN COMPLETE SECTIONS C AND D. IF YOU ANSWER "NO" TO QUESTIONS 2, 3, OR 4 BECAUSE THOSE CATEGORIES DO NOT APPLY TO YOU, YOUR ANSWER IS CONFIDENTIAL. THIS INFORMATION CAN ONLY BE USED FOR MEDI-CAL PURPOSES AND CANNOT BE USED BY THE INS FOR IMMIGRATION ENFORCEMENT UNLESS YOU ARE COMMITTING FRAUD. 2. Is the applicant an amnesty alien with a valid and current I-688?

Yes

No

3. Is the applicant a lawful permanent resident?

Yes

No

4. Is the applicant a PRUCOL alien?

Yes

No

IMPORTANT: All PRUCOL aliens must indicate their specific PRUCOL status in question 5. 5. If the applicant would qualify for Medi-Cal benefiWV as a PRUCO/Dlien, indicate the sWDtus category which entitles him/her tothat classification: A conditional entrant admitted to the United SWates before April 1, 1980 An alien paroled into the United States, including Cuban/Haitian entrants MC 13 (12/09)

4/7/2015 11:51 AM

p. 42

County of Orange

An alien subject to an Order of Supervision

Bid 017-C003095-GH

An alien granted an indefinite st ay of deportation An alien granted an indefinite volunt ary departure An alien on whose behalf an immediate relative petition (INS Form I-130) has been approved and who is entitled to voluntDry departure An alien who has properly filed an application for lawful permanent resident stDtus An alien granted a stay of deportation for a specified period An alien granted asylum A refugee admitted to the United SWates since April 1, 1980 An alien granted voluntary departure who is awaiting issuance of a visa An alien in deferred action stDtus An alien who entered and has continuously resided in the United SWates since before January 1, 1972, who would be eligible for an adjustment of status to lawful permanent resident pursuant to INA Section 249 (eligible as a Registry Alien) An alien granted a suspension of deportDtion whose departure INS does not contemplate enforcing An alien granted withholding of deportDtion pursuant to INA Section 243(h) An alien, not in one of the above categories, who can show that: (1) INS knows he/she is in the United States; and (2) INS does not intend to deport him/her, either because of the person’ s status category or individual circumstances SECTION C: VERIFICATION OF IMMIGRATION STATUS (FOR ALIENS WHO CLAIM SATISFACTORY IMMIGRATION STATUS) IMPORTANT: Complete this section only if you answered “yes” to questions 2, 3, or 4 in SECTION B on the front of this form. 1. Alien Registration number and/or Alien Admission number (INS Form I-94):

____________________________________________

2. Date the applicant first entered the United S tates:

____________________________________________

3. Applicant’s name when he/she first entered the United SWates:

____________________________________________

4. Of what country is the applicant a citizen:

____________________________________________

5. Where was the applicant born:

____________________________________________

SECTION D: SOCIAL SECURITY NUMBER Does the applicant have a Social Security number (SSN)? (Aliens who are not in a satisfactory immigration stDtus, and who do n ot have an SSN, can still get restricted Medi-Cal if they meet all eligibility requirementV.) Yes, the applicant’s Social Security number is:

____________________________________________

No SECTION E: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. Applicant signature

Date

Signature of person acting for applicant

Date

FOR COUNTY USE ONLY EW number: ________________________________ County: __________________________________ Date:____________________ Action taken: None necessary. SAVE primary verification performed. Date: ________________________ Document Verification Request (INS Form G-845) and copies of documentDtion of satisfactory immigration status sent to INS. Date: ____________________ Full Medi-Cal benefits were granted pending verification of immigration stDtus. Copies of alien status documents are in the case file. Person referred to INS to obt ain replacement documents. Date: ________________________ COUNTY DETERMINATION OF THE APPROPRIATE LEVEL OF MEDI-CAL BENEFITS. Based on the information provided on this form: The above named applicant is a U.S. citizen or national, or an alien, who, if otherwise eligible, would receive FULL Medi-Cal benefits. The above named applicant is an alien, who, if otherwise eligible, would receive RESTRICTED Medi-Cal benefits. MC 13 (12/09)

4/7/2015 11:51 AM

p. 43

State of California—Health and Human Services Agency

County of Orange

Bid 017-C003095-GH

Department of Health Care Services

STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS Print name of applicant (the applicant is the person who want s Medi-Cal)

Date

Print name of person acting for applicant

Relationship to applicant

SECTION A: MEDI-CAL BENEFITS TO CITIZENS AND ALIENS Citizens and nationals of the United States who meet all eligibility requirement s may receive full Medi-Cal benefits. Aliens who meet all eligibility requirements may receive either full Medi-Cal benefits (if they are in a satisfactory immigration status) or restricted benefits limited to emergency and pregnancy-related services (if they are not in a satisfactory immigration st atus). Satisfactory immigration st atus and full Medi-Cal benefit s for aliens: Federal and st ate law provide that full Medi-Cal benefits may be received only by aliens who are in a satisfactory immigration status and who meet all eligibility requirements including California residency. Aliens are in a satisfactory immigration status if they are amnesty aliens with valid and current lawful temporary resident cards (I-688) or lawful permanent residents or permanently residing in the U.S. under color of law (PRUCOL). The 16 PRUCOL categories are listed in SECTION B, question 5 below. Documented aliens not in a satisfactory immigration status who meet all eligibility requirements, including California residency , may receive restricted benefits (limited to emergency and pregnancy-related services). Undocumented aliens who meet all eligibility requirements, including California residency , may receive restricted benefits (limited to emergency and pregnancy-related services). Citizenship/immigration status information: Every person requesting Medi-Cal is required to provide information about his/her citizenship or immigration st atus. Immigration st atus information provided as part of the Medi-Cal application is confidential and cannot be used by the INS for immigration enforcement unless you are committing fraud. Alien status documents and verification requirements: Aliens who claim to be in a satisfactory immigration status (SIS) for Medi-Cal purposes must present INS documents that show their immigration status if they have an INS document or are eligible to obtain one. Aliens who claim to be in an SIS, but who cannot obtain an INS document or replacement receipt (for example, aliens in the last PRUCOL category indicated in SECTION B below) should submit other evidence establishing their immigration status. INS documents will be verified by the INS. Aliens who do not have these documents with them, or who have unreadable documents, may bring us receipts which show that they have applied for replacements. Aliens will have 30 days to do this, or until their Medi-Cal application is ruled on, whichever is longer. If the alien is otherwise eligible, Medi-Cal will be issued during this period and while the submitted documentation is being verified by the INS. If none of the documents contains the applicant's photograph, they must show us an identity document which establishes that the applicant is the person named in the documents. Social Security number requirement: Every person requesting Medi-Cal who has a Social Security number is asked to provide it to the county welfare department. U.S. citizens, U.S. nationals, and aliens claiming to be in a satisfactory immigration status who do not have a Social Security number must apply for one and provide it to the county welfare department. Aliens in satisfactory immigration status for Medi-Cal purposes who need help applying for a Social Security number should ask their eligibility worker for assistance. Aliens who are not in a satisfactory immigration status and who do not have a Social Security number can still get restricted Medi-Cal if they meet all eligibility requirements. SECTION B: CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Is the applicant a citizen or national of the United States?

❒ Yes

❒ No

If the applicant is a citizen or a national of the United States, where was he/she born? _______________________________________ (city, state)

IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE ANSWER QUESTIONS 2, 3, AND 4 BELOW (AND QUESTION 5 IF YOU CLAIM TO BE PRUCOL) THEN COMPLETE SECTIONS C AND D. IF YOU ANSWER "NO" TO QUESTIONS 2, 3, OR 4 BECAUSE THOSE CATEGORIES DO NOT APPLY TO YOU, YOUR ANSWER IS CONFIDENTIAL. THIS INFORMATION CAN ONLY BE USED FOR MEDI-CAL PURPOSES AND CANNOT BE USED BY THE INS FOR IMMIGRATION ENFORCEMENT UNLESS YOU ARE COMMITTING FRAUD. 2. Is the applicant an amnesty alien with a valid and current I-688?

❒ Yes

❒ No

3. Is the applicant a lawful permanent resident?

❒ Yes

❒ No

4. Is the applicant a PRUCOL alien?

❒ Yes

❒ No

IMPORTANT: All PRUCOL aliens must indicate their specific PRUCOL status in question 5. 5. If the applicant would qualify for Medi-Cal benefits as a PRUCOL alien, indicate the status category which entitles him/her to that classification: ❒

A conditional entrant admitted to the United States before April 1, 1980

❒

An alien paroled into the United States, including Cuban/Haitian entrants

MC 13 (12/09)

4/7/2015 11:51 AM

p. 44

County of Orange

Bid 017-C003095-GH

❒

An alien subject to an Order of Supervision

❒

An alien granted an indefinite st ay of deportation

❒

An alien granted an indefinite volunt ary departure

❒

An alien on whose behalf an immediate relative petition (INS Form I-130) has been approved and who is entitled to voluntary departure

❒

An alien who has properly filed an application for lawful permanent resident status

❒

An alien granted a stay of deportation for a specified period

❒

An alien granted asylum

❒

A refugee admitted to the United States since April 1, 1980

❒

An alien granted voluntary departure who is awaiting issuance of a visa

❒

An alien in deferred action status

❒

An alien who entered and has continuously resided in the United States since before January 1, 1972, who would be eligible for an adjustment of status to lawful permanent resident pursuant to INA Section 249 (eligible as a Registry Alien)

❒

An alien granted a suspension of deportation whose departure INS does not contemplate enforcing

❒

An alien granted withholding of deportation pursuant to INA Section 243(h)

❒

An alien, not in one of the above categories, who can show that: (1) INS knows he/she is in the United States; and (2) INS does not intend to deport him/her, either because of the person’ s status category or individual circumstances

SECTION C: VERIFICATION OF IMMIGRATION STATUS (FOR ALIENS WHO CLAIM SATISFACTORY IMMIGRATION STATUS) IMPORTANT: Complete this section only if you answered “yes” to questions 2, 3, or 4 in SECTION B on the front of this form. 1. Alien Registration number and/or Alien Admission number (INS Form I-94):

____________________________________________

2. Date the applicant first entered the United S tates:

____________________________________________

3. Applicant’s name when he/she first entered the United States:

____________________________________________

4. Of what country is the applicant a citizen:

____________________________________________

5. Where was the applicant born:

____________________________________________

SECTION D: SOCIAL SECURITY NUMBER Does the applicant have a Social Security number (SSN)? (Aliens who are not in a satisfactory immigration status, and who do n ot have an SSN, can still get restricted Medi-Cal if they meet all eligibility requirements.) ❒

Yes, the applicant’s Social Security number is:

❒

No

____________________________________________

SECTION E: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. Applicant signature

Date

Signature of person acting for applicant

Date

FOR COUNTY USE ONLY EW number: ________________________________ County: __________________________________ Date:____________________ Action taken: ❒ None necessary. ❒ SAVE primary verification performed. Date: ________________________ ❒ Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Date: ____________________ ❒ Full Medi-Cal benefits were granted pending verification of immigration status. ❒ Copies of alien status documents are in the case file. ❒ Person referred to INS to obt ain replacement documents. Date: ________________________ COUNTY DETERMINATION OF THE APPROPRIATE LEVEL OF MEDI-CAL BENEFITS. Based on the information provided on this form: ❒ The above named applicant is a U.S. citizen or national, or an alien, who, if otherwise eligible, would receive FULL Medi-Cal benefits. ❒ The above named applicant is an alien, who, if otherwise eligible, would receive RESTRICTED Medi-Cal benefits. MC 13 (12/09)

4/7/2015 11:51 AM

p. 45

State of California—Health and Human Services Agency

County of Orange

Bid 017-C003095-GH

Department of Health Care Services

NOTICE REGARDING TRANSFER OF A HOME FOR BOTH A MARRIED AND AN UNMARRIED

APPLICANT/BENEFICIARY

This is only a brief description of the Medi-Cal eligibility rules. For more detailed information, you should call your county welfare department. You will probably want to consult with an attorney, your local legal services program for seniors, or the local branch of the long-term care ombudsman program.

A transfer of property interest for less than fair market value in a Medi-Cal beneficiary’s home will not cause ineligibility for Medi-Cal benefits if at the time of the transfer, the home would have been considered an exempt resource.

He leído la notificación precedente y recibido una copia.

Esta es solamente una breve descripción de las reglas de Medi-Cal para tener derecho a beneficios. Para recibir información más detallada, llame al departamento de bienestar público de su condado. Usted probablemente deseará consultar con un abogado, con su programa local de servicios legales para las personas de edad avanzada o con la oficina local del programa de mediadores para la atención a largo plazo.

Una transferencia de interés sobre propiedad, por menos del valor equitativo de venta de la casa de un(a) beneficiario(a) de Medi-Cal, no causará que pierda el derecho para recibir los beneficios de Medi-Cal, si en el momento de la transferencia, la casa hubiera sido considerada un recurso exento.

NOTIFICACIÓN EN RESPECTO A LA TRANSFERECIA DE UNA CASA, PARA LOS

SOLICITANTES/BENEFICIARIOS, CASADOS Y SOLTEROS

I have read the above notice and have received a copy.

Fecha

Firma

Date

Signature

Este formulario pude ser firmado por el/la solicitante, el/la esposo(a) del solicitante, un(a) representante legal o un(a) agente, de existir alguno(a). La falta de firmar este documento no resultará en la pérdida de derecho para recibir atención médica.

p. 46

This form may be signed by the applicant, the applicant’s spouse, legal representative, or agent, if any. Failure to sign this form shall not result in ineligibility for medical assistance. 4/7/2015 11:51 AM

DHCS 7077 A (Eng/SP) (05/07)

County of Orange

4/7/2015 11:51 AM

Bid 017-C003095-GH

p. 47

County of Orange

Bid 017-C003095-GH

If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Check One) Already registered. I am registered to vote at my current residence address. Yes.

I would like to register to vote. (Please fill out the attached voter registration form.)

No.

I do not want to register to vote.

NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. YOU MAY TAKE THE ATTACHED VOTER REGISTRATION FORM TO REGISTER AT YOUR CONVENIENCE. ___________________________________________________________________ Applicant Name Date

Important Notices 1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. 2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private. 3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or other political preference, you may file a complaint with the Secretary of State by calling toll-free (800) 345-VOTE (8683) or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. For more information on elections and voting, please visit the Secretary of State’s website at www.sos.ca.gov. 01/13 NVRA Voter Preference Form

4/7/2015 11:51 AM

p. 48

County of Orange State of California – Health and Human Services Agency

Bid 017-C003095-GH Department of Health Care Services

BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)

The BCCTP may provide Medi-Cal to low-income people that live in California and have breast and/or cervical cancer. If you have been denied Medi-Cal or you are no longer eligible for Medi-Cal through your county and you have breast and/or cervical cancer, tell your county Eligibility Worker (EW). Your EW can make a referral for you to the BCCTP. An Eligibility Specialist (ES) from the BCCTP will call or write to you for more information. The requested information will help us to see if you are eligible for the program. You may be Medi-Cal eligible through the BCCTP if you are a woman and you meet the following requirements: 

    

Have been screened and found in need of treatment for breast and/or cervical cancer, follow-up care for cancer, or precancerous cervical lesions/conditions by an Every Woman Counts (EWC) or Family Planning, Access, Care and Treatment (FamPACT) provider; and Are a California resident; and Are under age 65; and Are a United States citizen or have satisfactory immigration status; and Have no other health insurance including full-scope no share-of-cost Medi-Cal, or Medicare; and Have a monthly gross family income, at the time of screening and diagnosis, that is at or below 200 percent of the federal poverty level.

If you have been screened for breast and/or cervical cancer by a provider that is not with EWC or FamPACT, you can still be referred to the BCCTP. Your BCCTP worker will help you find an EWC or FamPACT provider that can confirm your diagnosis. Even if you do not meet all the above requirements, you may still receive BCCTP through the State-funded BCCTP. The State-funded BCCTP can help you for up to18 months for breast cancer or up to 24 months for cervical cancer. The State-funded BCCTP is available to men and women, regardless of immigration status. For additional information or questions on the BCCTP, call 1-800-824-0088

MC Info Notice 372 (09/09)

4/7/2015 11:51 AM

p. 49

County of Orange

4/7/2015 11:51 AM

Bid 017-C003095-GH

p. 50

County of Orange State of California – Health and Human Services Agency

Bid 017-C003095-GH Department of Health Care Services

U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity A new law says most U.S. citizens or nationals applying to Medi-Cal must show proof of citizenship and proof of identity. Read below to see if this law applies to you.

If you are not a U.S. citizen, this law does not apply to you. The new law does not apply to U.S. citizens or nationals in any of these categories: • Anyone with: – Supplemental Security Income (SSI) – Medicare – Social Security Disability Insurance (SSDI) – Social Security Retirement and Survivors Insurance (RSI – Title II) based on their own disability • Anyone under 21 asking for Minor Consent Services • Babies born to women on Medi-Cal • Children in Foster Care, Adoption Assistance, or Kin-GAP • Babies in the Abandoned Baby Program • CalWORKs Beneficiaries

What if I am not one of the above people? If you are a U.S. citizen or national, you must provide proof of citizenship and identity to be eligible for Medi-Cal. (See page 3 for a list of acceptable proof of citizenship and identity.) U.S. nationals include people born in American Samoa (including Swains Island) and certain people from the Commonwealth of the Northern Mariana Islands.

What if I am NOT a U.S. citizen? If you are not a U.S. citizen or national, you only need to provide the same documents that were required before. Nothing has changed.

DHCS 0001 (05/09)

4/7/2015 11:51 AM

How can I get proof of citizenship? If you were born in California, the county may be able to get your birth record. (A birth record is proof of citizenship.) Fill out a Request for California Birth Record to ask the county to request your birth record. Then, mail or take this form to your local social services office. If a birth record cannot be found, you will need to provide another proof of citizenship. See page 3 for list of acceptable documents. Ask your county about getting proof of citizenship if you were not born in California. Contact the county to see if they have found a birth record match for you before you pay for a birth certificate.

Page 1 of 4

p. 51

County of Orange State of California – Health and Human Services Agency

What if I cannot provide proof of citizenship or identity? You should still apply now and provide proof later. If you cannot provide your proof now, and you meet all other eligibility requirements, you will receive full-scope benefits. After a reasonable amount of time, your full-scope benefits will be changed to limited benefits if you stop trying to provide the documents and are still eligible for Medi-Cal. Limited benefits cover emergency, pregnancy-related, and long-term care services. If your benefits are reduced to limited benefits and you provide proof within one year of your application date, your Medi-Cal benefits will be changed to full-scope starting from the date of you received limited benefits. If you incurred health costs while getting your citizenship and identity documents, Medi-Cal may pay for your bills. Call the Beneficiary Services Center at the Department of Health Care Services for answers to your questions: (916) 403-2007.

Do children have to provide proof of citizenship and identity, too? Yes. If your child was born in California, ask your county to request the birth record as proof of citizenship. If your child is under 16 and you have filled out and signed the Medi-Cal application or the Healthy Families/Medi-Cal joint application with your child’s date and place of birth, you do not need to provide proof of identity. (This signed application is proof of your child’s identity.) You will still have to provide proof of citizenship.

Bid 017-C003095-GH Department of Health Care Services

What if I need Medi-Cal before the county has time to process my application? Tell the county about your immediate need for medical care to speed up your application. In addition, many pregnant women and children can start receiving Medi-Cal right away by going to a doctor or clinic that participates in programs providing temporary Medi-Cal to them if eligible.

Do I have to provide proof of citizenship and identity every year? No. You only have to provide this information once – either when you first apply or on your next annual eligibility review.

Does this law affect my Food Stamps, CalWORKs, or Healthy Families benefits? No. The new citizenship and identity requirements apply to Medi-Cal only.

Do you need original citizenship and identity documents? Yes. We need the original citizenship and identity documents, or copies that have been certified by the issuing agency.

Can I mail my proof? Yes. The county will make copies and mail them back to you. Or, you can take your documents to your local social services office. Ask them to make copies and give them back right away.

If your child is 16 or over, you will still need to provide proof of identity for your child. See page 3. If your child applies through CHDP Gateway, a School Lunch Program, or the Healthy Families/Medi-Cal joint application, you do not have to provide proof until your county social services office asks you for it. DHCS 0001 (05/09)

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Acceptable Citizenship and Identity Documents The easiest way for U.S. citizens or nationals to prove citizenship and identity is with one of these documents: — U.S. Passport issued without limitation (expired ones are acceptable) — Certificate of Naturalization (N-550 or N-570) — Certificate of U.S. Citizenship (N-560 or N-561) – OR – If you do not have one of the documents above, provide… One citizenship document listed below:  U.S. Birth Certificate  Certification of Report of Birth (DS-1350)

 Federal or State census record that shows the applicant’s age and U.S. citizenship or place of birth

 Report of Birth Abroad of a U.S. Citizen (FS-240)

 Seneca Indian tribal census record * †

 State Department Certification of Birth (FS-545 or DS-1350)

 Bureau of Indian Affairs Navajo Indians tribal census record * †

 U.S. Citizen Identification Card (I-197 or I-179)

 U.S. State Vital Statistics birth registration notification * †

 American Indian Card (I-872)

 A delayed U.S. public birth record that was recorded more than 5 years after the person’s birth * †

 Northern Marianas Card (I-873)  Final adoption decree showing a U.S. place of birth  Proof of adoption of a child born outside U.S. and in the legal/physical custody of the U.S. citizen parent (IR-3 or IR-4)

 Proof of U.S. civil service employment before June 1, 1976  U.S. military service record showing a U.S. place of birth

 Statement signed by doctor or midwife present at the birth * †  Roll of Alaska Natives from the Bureau of Indian Affairs * †  Admission papers from a nursing or skilled care facility, or other institution that shows a U.S. place of birth * Medical record (not an immunization record) * † * Must be dated at least 5 years before your 1st Medi-Cal application and show a U.S. place of birth. † For children under 16, must be created near the time of birth.

 U.S. hospital record made at the time of birth * †  Life, health, or other insurance record * †  Religious record recorded in the U.S. within 3 months of birth showing U.S. place of birth and birth date or age  Early school record showing a U.S. place of birth, date of admission, birth date, names and places of birth of parents

You must provide a document as high up on the list as you can. If you cannot provide any of these citizenship documents… Ask two adults to fill out and sign an Affidavit of Citizenship. Both adults must have proof of their own identity and U.S. citizenship, and only one of them may be related to you.

– AND – One identity document listed below:  Driver's license issued by a U.S. State or Territory with a photograph or other identifying information  School Identification card with a photograph

 Three or more confirming documents, such as employee ID cards, high school or college diplomas, marriage licenses, divorce decrees, and property deeds/titles

 U.S. Military I.D. card or draft record

 Clinic, doctor, or hospital records for a child under 16

 Federal, state or local government I.D. card with same identifying information as a driver’s license

 School, nursery school, or daycare records, including report cards, for a child under 16. The county will verify with the school.

 U.S. Military dependent identification card  A U.S. passport (issued with limitation)  Certificate of Degree of Indian Blood or other U.S. American Indian/Alaska Native Tribal document

 For people with disabilities who live in a residential care facility, an Affidavit signed by the facility’s director or administrator

 U.S. Coast Guard Merchant Mariner Card DHCS 0001 (05/09)

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For a child under 16 who did not provide an Affidavit of Citizenship, you may submit:  An Affidavit of the child’s identity signed by the child’s parent, guardian, or caretaker relative with date and place of birth  A Medi-Cal application or the Healthy Families/Medi-Cal joint application that shows the child’s date and place of birth, and is signed by the child’s parent, guardian, or caretaker relative. For a child under 18, an Affidavit of the child’s identity signed by the child’s parent, guardian, or caretaker relative may be used if school ID cards or driver licenses are not available. Note: Expired identity documents are acceptable proof of identity.

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State of California —Health and Human Services Agency

Department of Health Care Services

MEDI-CAL GENERAL PROPERTY LIMITATIONS

FOR INDIVIDUALS WHO ARE NOT ELIGIBLE USING THEIR MODIFIED ADJUSTED GROSS INCOME Note: Medi-Cal disregards property for individuals whose eligibility is determined utilizing your Modified Adjusted Gross Income (MAGI). If you do not know if you are eligible using MAGI rules, you may ask your eligibility worker. If you have not yet applied, you may do so through your county department of health and human services or you may apply on-line at www.CoveredCA.com or by phone at 1-800-300-1506. This information notice provides a general overview of Medi-Cal property requirements for all Medi-Cal applicants and beneficiaries who are not eligible using their Modified Adjusted Gross Income. Property is defined as “real property” and “personal property”. “Real Property” is land, buildings, mobile home which are taxed as real property, life estates in real property, mortgages, promissory notes, and deeds of trust. “Personal property” is any kind of liquid or non-liquid asset, i.e., cars, jewelry, stocks, bonds, financial institution accounts, boats, trucks, trailers, etc. Property that is not counted in determining your eligibility is called “exempt” or “unavailable” property. Countable property (property which is not exempt or unavailable) is included in the “property reserve.” Your countable property must not exceed the property reserve limit. Any amount over the property reserve limit will make you and/or your family ineligible for Medi-Cal. To be eligible for Medi-Cal you may reduce your property to the property reserve limit before the end of the month in which you are requesting Medi-Cal. If you are unable to reduce your property limit for a month beginning with the month of application, see the “Exception: Principle v. Belshé” section on page 3. To be eligible for Medi-Cal, your countable property may not exceed the following property reserve limits: Number of Persons Whose Property is Considered 1 2 3 4 5 6 7 8 9 10 or more

Property Limit $2,000 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200

NOTE: When there is an Institutionalized spouse with a community spouse, an additional amount of countable property is allowed and jewelry is exempt regardless of its value. See page 2 for additional information. PROPERTY EXEMPTIONS

Personal Property

Real Property • Principal residence. Property used as a home is exempt (not counted in determining eligibility for Medi-Cal). When an applicant or beneficiary is absent from the house for any reason, including Institutionalization, the home will remain exempt if the applicant or beneficiary intends to return home someday. The home also continues to be exempt if the applicant’s or beneficiary’s spouse or dependent relative continues to live in it. Money received from the sale of the home can be exempt for six months if the money is going to be used for the purchase of another home. • Other real property. Up to $6,000 of the equity value in nonbusiness real estate (excluding the home), mortgages, deeds of trust, or other promissory notes may be exempt. In order to receive this exemption, the property must produce an annual income of 6 percent of the net market value or current face value. • Real property used in a business or trade. Real estate used in a trade or business is exempt regardless of its equity and whether it produces income.

• One motor vehicle. • Personal property used in a trade or business. • Personal affects. This includes clothing, heirlooms, weddings and engagement rings, and other jewelry with a net value of under $100. • Household items. • IRAs, KEOGHs, and other work-related pension plans. These funds are exempt if the family member whose name it is in does not want Medi-Cal. If held in the name of a person who wants Medi-Cal and payments of principal and interest are being received, the balance is considered unavailable and it is not counted. • Irrevocable burial trusts or irrevocable prepaid burial contracts. • One revocable burial fund or revocable prepaid burial contract with a value of up to $1,500 plus accrued interest per person. • Burial space items. • Musical instruments. • Recreation items including TVs, VCRs, computers, guns, collection, etc. • Livestock, poultry, or crops. • Countable property equal to the amount of benefits paid under a state-certified, long-term care insurance policy. • Life insurance policies. Each person may have life insurance policies with a combined face value of $1,500 or less accrued interest and dividends.

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PROPERTY LIMITS FOR INDIVIDUALS ENTERING OR RESIDING IN LONG-TERM CARE

WHO ARE NOT ELIGIBLE USING THEIR MODIFIED ADJUSTED GROSS INCOMES

If you are SINGLE and residing in a long-term care facility, you must have $2,000 or less in your property reserve. If you are MARRIED and BOTH of you live in a long-term care facility or residential care and neither of you has previously applied for Medi-Cal, your separate property plus one-half of the community property must be valued at $2,000 or less. Your spouse not applying for Medi-Cal may keep all of his/her separate property plus one-half of the community property. In this situation, the spouses may be able to hasten Medi-Cal eligibility by entering into an agreement that divides their community property. The advice of a knowledgeable attorney should be obtained prior to the signing of this type of agreement. If you are MARRIED and are admitted to a long-term care and you are expected to remain for at least 30 consecutive days, and you have a spouse who is living in the community, then your community spouse may keep a certain amount of the combined community and separate property. This amount is called the Community Spouse Resource Allowance (CSRA) and is calculated based on the day you apply for Medi-Cal. Increases are effective on January 1 of each year. The CSRA for the year 2015 is $119,220. The institutionalized spouse (spouse in the long-term care facility) may keep up to an additional $2,000 of countable property. The CSRA limit may be increased if: • The community spouse obtains a court order for his/her support, or • It is determined through a fair hearing that both of the following conditions exist: a. A greater amount of property is necessary to generate income sufficient to raise the community spouse’s income to the minimum monthly maintenance needs allowance (MMMNA). The MMMNA for the year 2015 is $2,981 per month. b. Additional income is necessary due to the exceptional circumstances resulting in financial duress. NOTE: Because these rules affect how much money a community spouse may retain for purposes of the institutionalized spouse’s Medi-Cal eligibility, you may want to consult a legal services program for seniors in your area or a private attorney familiar with the Medi-Cal program for more information on how the law affects you. ASSESSMENT

An institutionalized individual or his/her spouse may request an assessment of their property even if the institutionalized individual is not applying for Medi-Cal. If you would like to have an assessment completed, you must make an appointment at a county welfare department of health and human services. In order to complete the assessment, you will need to bring verification of the values of all your real and personal property. This verification may include such things as county tax assessments, checking account statements, savings account passbooks, court orders, brokerage account statements, life insurance policies, annuity policies, trust account documents, contracts, lease agreements, life estate documents, and/or documents from qualified persons of financial institutions about the values of any real or personal property belonging to you and your spouse. REDUCTION OF PROPERTY TO WITHIN PROPERTY LIMITS

THE PROPERTY RESERVE MUST BE REDUCED TO AN AMOUNT AT OR BELOW THE PROPERTY LIMIT BY THE END OF THE MONTH BEFORE MEDI-CAL MAY BE APPROVED FOR THAT MONTH. Medi-Cal eligibility cannot be approved for a month unless countable property is below the property limit at some time during that calendar month. If you are unable to reduce your property to the property limit for a month, beginning with the month of application, see the “Exception: Principe v. Belshé” section on page 3. For example: A Medi-Cal applicant whose total non-exempt property consists of a savings account with a balance of $3,300 in a month must reduce the savings account to $2,000 in that month. In this same situation, where there is a couple, the savings must be reduced to $3,000. If an institutionalized spouse and a community spouse have combined property totalling more than the CSRA plus $2,000 in a month, the couple will need to reduce the total non-exempt property to at or below the CSRA plus $2,000 to meet the property requirements. The institutionalized spouse will then have at least 90 days (longer if a court order is necessary) to complete transfer(s) of the property contained in the CSRA to the community spouse, bringing the institutionalized spouse to within $2,000, the property limit for one. The current CSRA for the year 2015 is $119,220. MC Information Notice 007 (01/15) ENG 4/7/2015 11:51 AM

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A Medi-Cal applicant may reduce his or her non-exempt property to within the specified limits in any way he or she chooses within the calendar month for which Medi-Cal is being requested. An applicant who is not institutionalized will not be ineligible due to a transfer of non-exempt property for less than fair market value unless the individual is institutionalized within 30 months of the date of the transfer. A transfer of non-exempt property for less than fair market value is a change in the ownership of the property by giving away, selling, or otherwise exchanging it for less than the property is worth. IMPORTANT NOTE: If you are applying as an institutionalized individual or if you may be institutionalized within 30 months of the date of a transfer, non-exempt property transferred for less than fair market value may result in a period of ineligibility for nursing facility level of care under Medi-Cal. The following are ways to reduce non-exempt property without incurring a period of ineligibility for nursing facility level of care: • • • • • • •

Pay medical bills Buy furnishings for the home Pay on the home mortgage Buy clothes Make repairs to the home Pay off your auto loan Pay off other debts

• Begin process to liquidate non-liquid assets such as obtaining the cash surrender value on non-exempt life insurance policies, list property for sale with qualified broker etc. • Borrow against excess property to cover the cost of medical care or request the medical provider to place a lien against the property to cover the cost of the care.

Exception: Principe v. Belshé provides that individuals who were unable to reduce their excess property during the month of application or some later month during the application process may spend down their property retroactively on qualified medical expenses. Qualified medical expenses are medical expenses that were incurred in any month and that were unpaid in the same month where there was excess property for the entire month. Eligibility will be granted, as otherwise eligible, after payment of those qualified medical expenses, with the excess property, occurs and verification of the payment is provided to the county. TRANSFERS OF EXEMPT PROPERTY

The transfer of exempt property at any time (property which is not counted) will not result in a period of ineligibility as long as the property would have been considered exempt at the time of the transfer. This includes a transfer of property used as a home or former home. However, the money received from the sale of a home will be counted as property unless the money is to be used for the purchase of another home within six months. In addition, any money received from the sale of other exempt assets will be counted as property. TRANSFERS OF NON-EXEMPT PROPERTY

An institutionalized applicant or someone who is already receiving Medi-Cal who is institutionalized within 30 months of the date of the transfer may be ineligible due to a transfer of non-exempt property for less than fair market value. Non-exempt property may be transferred without incurring a period of ineligibility if the property is transferred to: • The spouse (or to another for the sole benefit of the spouse) or to • A child of the institutionalized individual who is blind or permanently and totally disabled. Or, if • The property was intended to be transferred at fair market value for something of equal value, or • The property was not transferred to establish Medi-Cal eligibility, or • A period of ineligibility for nursing facility level of care would work an undue hardship. A transfer of the non-exempt former home to someone listed below or the transfer of exempt property to anyone will not result in a period of ineligibility for nursing facility level of care if the property was given away, sold, or otherwise exchanged at less than fair market value. If the non-exempt former home is transferred for less than fair market value to other individuals or non-exempt property is transferred for less than fair market value, then the transfer may result in a period of ineligibility for nursing facility level of care. The period of ineligibility could last from 1 to 30 months. This period of ineligibility is based on the uncompensated value of the property (dollar amount of compensation not received) divided by the statewide average rate for privately paid nursing facility care. The statewide average private pay rate for the year 2014 is $7,628 per month.

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For example: Assume an institutionalized individual reduces property by transferring $24,000 in excess property to a son or daughter as a gift. He/she would be ineligible for nursing facility level of care because the individual received nothing in fair market value in return for the gift. Suppose that the statewide average rate for privately paid nursing care is $3,000. This institutionalized individual would be ineligible for nursing facility level of care for eight months starting with the month of the transfer ($24,000 divided by $3,000 average private pay rate). The institutionalized individual will still be eligible for all other Medi-Cal services.

TRANSFER OF THE NON-EXEMPT FORMER HOME BY AN INSTITUTIONALIZED

INDIVIDUAL WHICH DOES NOT RESULT IN A PERIOD OF INELIGIBILITY

The transfer of the exempt home shall not result in a period of ineligibility. A transfer of the non-exempt former home also shall not result in a period of ineligibility if title of the home is transferred to: • • • •

The spouse, or A child under 21, or A child, regardless of age, who is blind or totally and permanently disabled, or A son or daughter not listed above, who resided in the home for two years immediately preceding the institutionalized individual’s date of admission and who provided care which allowed that individual to reside at home rather than in the institution or facility, or • A sibling who has equity interest in the home and who resided in the home for one year immediately preceding the date the institutionalized individual was admitted to the facility or institution. Prior to applying a period of ineligibility for nursing facility level of care, the county must determine if undue hardship exists. Anytime a transfer results in a period of ineligibility, the ineligible individual has the right to request an appeal through fair hearing. The form for filling a request is on the reverse side of the Notice of Action form discontinuing, denying, or restricting Medi-Cal eligibility.

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You cannot get your wheelchair into examination, interview rooms or restrooms. Men get referred to job training for better paying jobs than women. The county does not want you to have training because they say you are “too old.” You are not allowed to adopt a baby because you are of a different race.

DISCRIMINATION COMPLAINTS

If you think you have been discriminated against, you may submit a complaint application separately to the County or the State, and the Federal Government. The Federal agency that you must complain to depends on which program your complaint is about. You can file a discrimination complaint with: 1. FOR ALL PROGRAMS ADMINISTERED BY YOUR COUNTY WELFARE DEPARTMENT: The County’s Civil Rights Coordinator. Ask your county office for the name, address and phone number of their Civil Rights Coordinator. He/she will independently investigate your complaint. 2. Civil Rights Bureau California Department of Social Services 744 P Street, MS 8-16-70 Sacramento, CA 95814 (916) 654-2107 (866) 741-6241 (Toll-Free) 3. FOR THE CALFRESH PROGRAM: United States Department of Agriculture Director, Office of Civil Rights, Room 326-W, Whitten Bldg. 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 (202) 720-6382 (voice and TTY) 4. FOR ALL OTHER PROGRAMS: Health and Human Services Office of Civil Rights 90 7th Street, Suite 4-100 San Francisco, CA 94103 (415) 437-8310 (voice) (415) 437-8311 (TDD)

TIME LIMITS TO TAKE ACTION If you suffer discrimination, you must submit your complaint within 180 days of the actual discrimination. If the discrimination also affected the level of your benefits and services, you must also ask for a state hearing within 90 days. A discrimination investigation cannot change your benefit levels or services…only a state hearing can do that.

LIMITS ON CERTAIN RIGHTS Although you have the right to privacy and confidentiality, there are certain laws that allow limited exceptions. You can ask the county for the laws.

QUESTIONS

If you have any questions about the rights listed here, call the Public Inquiry Unit: toll free (800) 952-5253. The TDD toll-free telephone number is (800) 952-8349. ■

Adoption Assistance Program (AAP) Adult Protective Services Alcohol and Drug Program California Food Assistance Program (CFAP) Medi-Cal CalWORKs CalWORKs Child Care CalWORKs Welfare-to-Work Program/Services Cash Assistance Program for Immigrants (CAPI) Child Welfare Services Denti-Cal Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) CalFresh (Food Stamps) Foster Care In-Home Support Services Kinship Guardian Assistance (Kin-GAP) Mental Health

PROGRAMS COVERED BY THIS PAMPHLET ■ ■

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Multipurpose Senior Services Program (MSSP) Personal Care Services Program (PCSP) Refugee Cash Assistance Social Services

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES

This pamphlet is available from your Local County Welfare Office and at www.cdss.ca.gov in the following languages: • Arabic • Japanese • Russian • Armenian • Korean • Spanish • Cambodian • Lao • Spanish Large Print • Chinese • Tagalog • Mien • Farsi • Portugese • Ukranian • Hmong • Punjabi • Vietnamese Also Available in large print, Braille, and Audio CD PUB 13 (6/11)

YOUR RIGHTS

UNDER CALIFORNIA WELFARE PROGRAMS

… for people applying for or receiving public aid in California

Tell us if you need help because of a disability

Ask for a free interpreter

County of Orange

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1. Understand what is happening with your application and aid.

YOU HAVE A RIGHT TO…

All people and organizations providing public assistance must respect your rights. They can help you understand and apply for benefits and services.

YOUR RIGHTS

1. Keep records of all your information, documents, and contacts with the county. 2. Get a receipt when you turn anything in. 3. You can bring someone with you to a meeting with your worker. 4. Complain. There are 4 ways to do this: ■ Informal: You can ask to speak to a supervisor to talk about problems with a worker or to go over the rules and the proposed action on your aid or services. ■ State Hearing: Ask for a state hearing if there is a problem with your aid or services. You must ask for a hearing within 90 days of the county's action. You may be able to file after 90 days if you have a good reason, like illness or a disability. ■ Discrimination complaint: If you feel that the county has discriminated against you, you can make a discrimination complaint to the County’s Civil Rights Coordinator or to the State Civil Rights Bureau, and to the Federal Government. You must do this within 180 days of the discrimination. For more on this, see the section beginning “Prohibited Discrimination.”

IF YOU ARE HAVING PROBLEMS WITH YOUR AID OR SERVICES:

2. Get written and oral explanations about your application and aid. 3. Get a receipt for any documents you turn in. 4. See your case record. 5. See state and county laws and regulations. 6. Ask a judge to review any county decision about your eligibility, benefits, or services. 7. Not face discrimination in receiving program benefits or services. 8. File a complaint about discrimination. 9. Get extra help from county staff to make sure you get your benefits if you have a disability or impairment that makes it hard to understand the program rules. 10. Have your information kept confidential. 11. Be treated with courtesy and respect. You can ask for a state hearing any time you disagree with a county’s action on your benefits or services. You can also ask for a state hearing if the county is not giving you benefits or services which you think you should get. A state hearing is heard by a state Administrative Law Judge. The county will have someone at the hearing to explain why they took their action. A state hearing is not a court hearing. You do have the right to have a representative with you. There are free legal services in every county. They are listed on the back of your county notices. You can bring witnesses. You have the right to a free interpreter. Ask the county how to get one. • If your problem is with General Assistance or general relief, you must ask for a county hearing. • If your problem is with Social Security benefits, you must contact the Social Security Administration.

The county must give you a notice at least 10 days before any action to change your aid or services takes place. If you ask for a hearing before the action takes place, you can get “aid paid pending” your hearing. This means your aid stays the same until you get a hearing decision. You MUST ask for a hearing on any new notice you get, if you disagree.

CONTINUING YOUR AID OR SERVICES PENDING A STATE HEARING

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If the discrimination also affects your benefits or services, you must also ask for a state hearing if you wish to challenge the county’s decision on your benefits or services. Grievance: You can file a complaint with the county if they have a grievance procedure. This does not protect your beneﬁts in the way that asking for a state hearing does.

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The County does not give you a free interpreter. A worker tells a certain ethnic group about more programs and services than people of other ethnicities. The County won’t help you get audio tapes of a program orientation to help you with a disability that makes it hard for you to read. A worker learns of your religion or politics and then treats you differently. You can’t get to appointments because the county building does not have an elevator.

EXAMPLES OF DISCRIMINATION

Under State law, welfare agencies may not provide you aid, benefits or services that is different from aid provided to others on the basis of Race, Color, National Origin (including language), Ethnic Group Identification, Age, Disability, Religion, Sex, Sexual Orientation, Political Affiliation, Marital Status, or Domestic Partnership Federal laws also prohibit discrimination on several, although not all, of the bases listed above. Federal Law also prohibits : 1. Delaying or denying the placement of a child for adoption or into foster care on the basis of race, color or national origin of the adoptive or foster parents, or the child; 2. Denying to any individual the opportunity to become a foster or adoptive parent on the basis of race, color or national origin of the individual or child involved.

PROHIBITED DISCRIMINATION

1. Phone: Ask for a State Hearing by contacting the CA Department of Social Services at (800) 743-8525 or (800) 952-5253 2. Fill out the back of your Notice of Action (NOA) or send a written request to: CDSS, State Hearing Division 744 P Street M.S. 09-17-37 Sacramento, CA 95814

HOW TO REQUEST A STATE HEARING

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CalOptima Manages Your Medi-Cal Benefits in Orange County CalOptima is the Medi-Cal managed care program for Orange County. Most Medi-Cal eligible residents in Orange County get their health care through CalOptima. Choosing a health network and primary care physician is important When your Medi-Cal is approved, and you are a CalOptima member, you will need to choose a health network and a primary care physician (PCP). Your health network and PCP will arrange for all your health care services. This includes preventive care, shots and well-care visits. You will soon receive information from CalOptima about how to choose a health network and PCP. Watch your mail for your New Member Packet. It contains a Health Network Selection Form that you must complete and return to CalOptima right away. If you do not choose a health network, CalOptima will choose one for you.

annual Open Enrollment Period to change your health network. You can change your PCP within your health network every 30 days. Call us for help with your CalOptima/Medi-Cal benefits If you have questions about your CalOptima/MediCal benefits or need help choosing a health network and PCP, call CalOptima’s Customer Service Department at 1-714-246-8500, or toll-free at 1-888587-8088, Monday through Friday, from 8 a.m. to 5:30 p.m. Members with hearing or speech impairments can call our TDD line at 1-714-2468523. We have staff who speak your language.

Pregnant? If you or your Medi-Cal eligible family member is You can make changes to your health network within pregnant, call CalOptima’s Customer Service Department right away. the first three months of becoming a CalOptima member. After that, you must wait for CalOptima’s

CalOptima administra sus beneficios de Medi-Cal en el Condado de Orange CalOptima es el programa que administra el cuidado de salud para beneficiarios de Medi-Cal en el Condado de Orange. La mayoría de los residentes elegibles en el Condado de Orange reciben su cuidado de salud a través de CalOptima. Es importante escoger un plan de salud y un médico general Cuando su Medi-Cal es aprobado, y usted es miembro de CalOptima, necesitará escoger un plan de salud y un médico general (también conocido como PCP por sus siglas en inglés). Su plan de salud y su médico general coordinarán todos sus servicios del cuidado de salud. Esto incluye el cuidado preventivo, vacunas y chequeos generales. 4/7/2015 11:51 AM

Pronto recibirá información por correo de CalOptima sobre cómo escoger un plan de salud y un médico general. Esté al pendiente de su correo puesto que recibirá un Paquete de Miembro Nuevo. El paquete contiene un Formulario de Selección de Planes de Salud que usted necesitará completar y regresar a CalOptima lo más pronto posible. Si usted no escoge un plan de salud, CalOptima escogerá uno por usted. p. 61

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Usted puede hacer cambios a su plan de salud dentro de los primeros tres meses de haber obtenido elegibilidad como miembro de CalOptima. Después de ese tiempo, usted tendrá que esperar por el Periodo Anual de Inscripción Abierta de CalOptima para cambiar su plan de salud. Usted puede cambiar de médico general dentro de su plan de salud cada 30 días. Llámenos si necesita ayuda con sus beneficios de CalOptima/Medi-Cal Si tiene preguntas sobre sus beneficios de CalOptima/Medi-Cal o si necesita ayuda para escoger

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un plan de salud y un médico general, llame al Departamento de Servicios para Miembros al 1-714246-8500, o gratuito al 1-888-587-8088, de lunes a viernes de las 8:00 a.m. hasta las 5:30 p.m. Miembros con problemas auditivos o impedimentos del habla pueden llamar a nuestra línea TDD al 1-714-2468523. Tenemos personal que habla su idioma. ¿Está embarazada? Si usted o su miembro de la familia elegible con Medi-Cal está embarazada, llame al Departamento de Servicios para Miembros de CalOptima lo más pronto posible.

CalOptima qun tr phúc li Medi-Cal ca quý v Qun Orange CalOptima là chng trình qun tr y t cho Qun Orange. Hu ht nh ng ng i th h ng Medi-Cal Qun Orange nhn c các dch v chm sóc sc khe qua CalOptima. Vic ch n nhóm y t và bác s gia ình là m t iu rt quan tr ng Sau khi quý v c chp thun cho Medi-Cal và quý v là thành viên ca CalOptima, quý v cn chn mt Nhóm Y T và Bác S Gia ình (PCP). Nhóm Y T và Bác S Gia ình s sp xp tt c dch v chm sóc sc khe ca quý v bao gm dch v chm sóc sc khe phòng nga, chích nga và khám sc khe

nh k. Quý v s nhn c các thông tin ca CalOptima liên quan n vic chn Nhóm Y T và Bác S Gia ình. Hãy nh ! ý n tp Tài Liu Dành Cho Thành Viên Mi c g"i n quý v qua ng bu

in. Tp tài liu này gm có n Xin Chn Nhóm Y T mà quý v phi i#n y và g"i l$i cho CalOptima ngay lp tc. N u quý v không ch n nhóm y t , CalOptima s ch n cho quý v. Quý v có th! thay %i Nhóm Y T ca quý v trong vòng 3 tháng u tiên sau khi ã tr thành thành viên ca CalOptima. Sau ó, quý v phi i n Th i

Gian M S% Ghi Danh hàng nm ca CalOptima !

%i Nhóm Y T. Quý v có th! %i Bác S Gia ình trong cùng mt nhóm y t m&i 30 ngày. Xin g i cho chúng tôi n u quý v cn s giúp v các phúc li CalOptima/Medi-Cal Nu quý v có bt c câu hi gì v# phúc li CalOptima/Medi-Cal hc cn s' giúp * trong vic chn Nhóm Y T và Bác S Gia ình, xin gi Vn Phòng Dch V CalOptima t$i s+ 1-714-246-8500 ho9c s+ in tho$i mi;n phí 1-888-587-8088, Th Hai n Th Sáu, t 8:00 gi sáng n 5:30 chi#u. Thành viên suy thính giác ho9c có khó khn phát âm có th! gi ng dây TDD t$i s+ 1-714-246-8523. Chúng tôi có nhân viên nói ngôn ng ca quý v. ang Mang Thai? Nu quý v ho9c thành viên trong gia ình th h ng Medi-Cal ang mang thai, xin gi Vn Phòng Dch V CalOptima ngay lp tc.

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Department of Health Care Services

Medi-Cal Services for Children and Young Adults: Early & Periodic Screening, Diagnosis & Treatment Mental Health Services

This notice is for children and young adults (under age 21) who qualify for Medi-Cal EPSDT services and their caregivers or guardians

What are EPSDT Services? • • •

EPSDT mental health services are Medi-Cal services that correct or improve mental health problems that your doctor or other health care provider finds, even if the health problem will not go away entirely. EPSDT mental health services are provided by county mental health departments. These problems may include sadness, nervousness, or anger that makes your life difficult. You must be under age 21 and have full scope Medi-Cal to get these services.

How to get EPSDT Services for yourself (under age 21) or your child Ask your doctor or clinic about EPSDT services. You or your child may receive these services if you and your doctor, or other health care provider, clinic (such as the Child Health and Disability Prevention Program), or county mental health department agree that you or your child need them. You may also call your local county mental health department directly. The call is free.

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Types of EPSDT Services Some of the services you can get from your county mental health department are: • • • • • • •

Individual therapy Group therapy Family therapy Crisis counseling Case management Special day programs Medication for your mental health

Counseling and therapy services may be provided in your home, in the community, or in another location. Your county mental health department, and your doctor or provider will decide if the services you ask for are medically necessary.

County mental health departments must approve your EPSDT services. Every county mental health department has a tollfree phone number that you can call for more information and to ask for EPSDT mental health services.

What are EPSDT Therapeutic Behavioral Services? Therapeutic Behavioral Services (TBS) are an EPSDT specialty mental health service. TBS helps children and young adults who: • Have severe emotional problems; • Live in a mental health placement or are at risk of placement; or • Have been hospitalized recently for mental health problems or are at risk for psychiatric hospitalization. If you get other mental health services and still feel very sad, nervous, or angry, you may be able to have a trained mental health coach help you. This person could help you when you have problems that might cause you to get mad, upset, or sad. This person would come to your home, group home or go with you on trips and activities in the community. MC 003 (11/12) p. 67

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Your county mental health department can tell you how to ask for an assessment to see if you need mental health services including TBS.

You can ask for a state hearing within 90 days after exhausting the county mental health department’s appeal process by doing one of the following:

Who can I talk to about EPSDT mental health services?

• Call: 1-800-952-5253, or for TTY 1-800-952-8349;

Your doctor, psychologist, counselor, social worker, or other health or social services provider can assist you with finding EPSDT mental health services. For children and young adults in a group home or residential facility, talk to the staff about getting additional EPSDT services.

• Write: California Department of Social Services, State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430.

For children in foster care, consult the child’s court-appointed attorney. You can also call your county mental health department directly. (Look in your phone book for the toll-free telephone number, or call the Department of Health Care Services Mental Health Ombudsman’s Office).

• Fax:

916-651-5210; or 916-651-2789

Where can I get more information? For more information please contact the following offices at the telephone numbers below. County Mental Health Department toll–free access number Look in your local phone book

What if I don’t get the services I want from my county mental health department?

Department of Health Care Services Mental Health Ombudsman’s Office 1-800-896-4042

You can file an appeal with your county mental health department if they deny the EPSDT services requested by your doctor or provider. You may also file an appeal if you think you need mental health services and your provider or county mental health department does not agree.

Department of Health Care Services website

Call the county mental health department’s toll-free number to talk to a Problem Resolution (grievance/ appeal) coordinator for information and help. You may also call the county patients’ rights advocate, or the Department of Health Care Services, Mental Health Ombudsman Office.

www.dhcs.ca.gov/services/mh www.dhcs.ca.gov/services/mh/pages/EPSDT.aspx

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www.dhcs.ca.gov For additional information about mental health and EPSDT, please go to the following webpages:

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Language Services Notice If you do not understand this information or notification, call your county Medi-Cal worker. You have the right to interpreter services provided by the county at no cost to you. Si no entiende esta información o notificación, llame al trabajador de Medi-Cal de su condado. Tiene derecho a obtener servicios de intérpretes proporcionados por el condado sin costo para Ud. (Spanish)

‫ ﻟﺪﻳﻚ ﺣﻖ اﳊﺼﻮل ﻋﻠﻰ ﺧﺪﻣﺎت‬.‫ اﳋﺎص ﲟﻘﺎﻃﻌﺘﻚ‬Medi-Cal ‫ إﺗﺼﻞ ﲟﻮﻇﻒ‬، ‫إذا ﻟﻢ ﺗﻔﻬﻢ ﻫﺬه اﳌﻌﻠﻮﻣﺎت أو ﻫﺬا اﻹﺑﻼغ‬ (Arabic) .‫ﺗﺮﺟﻤﺔ ﻣﺠﺎﻧﻴﺔ ﻣﺘﻮﻓﺮة ﻟﻚ ﻣﻦ ﻗِﺒﻞ اﳌﻘﺎﻃﻌﺔ‬

如果您不理解此處的資訊或通知,請電洽您所在縣的Medi-Cal工作人員。您有權免費獲得縣政府提供的免費口譯服務。 (Chinese)

‫ ﺷﻤﺎ اﻳﻦ ﺣﻖ را دارﻳﺪ ﻛﻪ‬.‫ ﻛﺎﻧﺘﻲ ﺧﻮد ﲤﺎس ﺑﮕﻴﺮﻳﺪ‬Medi-Cal ‫ ﺑﺎ ﻣﺪدﻛﺎر‬،‫اﮔﺮ اﻳﻦ اﻃﻼﻋﺎت و ﻳﺎ اﻃﻼﻋﻴﻪ را درك ﳕﻲ ﻛﻨﻴﺪ‬ (Farsi) .‫ﺑﻪ ﻃﻮر راﻳﮕﺎن از ﺧﺪﻣﺎت ﻣﺘﺮﺟﻢ از ﻃﺮﻳﻖ ﻛﺎﻧﺘﻲ اﺳﺘﻔﺎده ﻛﻨﻴﺪ‬ Yog koj tsis totaub txog cov kev qhia lossis tsab ntawv no, hu rau koj tus neeg tuav ntaub ntawv Medi-Cal hauv lub county. Koj muaj cai tau txais kev pab txhais lus dawb los ntawm lub county. (Hmong)

‫҆܄@ێ‬Ǧ@ࣃ‫ݖ‬Էθ@‫ێ‬६०@ր@‫ؾ‬ɜ@Ĉ‫مڐ‬ɜ@ࠥ‫@ࣲڒ‬mMc@ɽʁ@‫مڜݗ‬ö@‫۾‬টॣֲ֫٤N@ Ãۖۜɜ@ࠥ‫ࣲڒ‬Ã@ЛΕ΂@‫܆‬Ěॣɜ@ࣃَ@Էҿ֢θ@ю‫@ڽ‬ŇπÃ@ۘ֨ɩɳN (Korean) Если вы не понимаете данную информацию или уведомление, позвоните сотруднику компании Medi-Cal вашего округа. У вас есть право на получение услуг переводчика, которые предоставляются округом бесплатно. (Russian) Kung hindi ninyo naiintindihan ang impormasyon o paunawang ito, tawagan ang inyong manggagawa sa Medi-Cal ng county. Kayo ay may karapatang magkaroon ng mga serbisyo ng tagasalin na ibibigay ng county na walang bayad sa inyo. (Tagalog) Neáu quyù vò khoâng hieåu chi tieát hoaëc thoâng baùo naøy, haõy ñieän thoaïi cho nhaân vieân Medi-Cal taïi quaän quyù vò. Quyù vò coù quyeàn ñöôïc quaän cung caáp dòch vuï thoâng dòch mieãn phí cho quyù vò. (Vietnamese)

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Table Of Contents 1. Medi-Cal – What it Means to You. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Who Can Get Medi-Cal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3. Medi-Cal for Persons with Disabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4. Medi-Cal and Your Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5. Medi-Cal and Your Property/Assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 6. Proof of California Residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7. Where to Apply for Medi-Cal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 8. How to Apply for Medi-Cal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 9. Required Documents to Apply for Medi-Cal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 10. When You Need to Pay a Share of Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 11. How to Meet Your Share of Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 12. Private Health Insurance and Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 13. Medi-Cal May Pay Private Health Insurance Premiums. . . . . . . . . . . . . . . . . . . . . . . . 9 14. The Medi-Cal Identification Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 15. What the Benefits Identification Card (BIC) Looks Like . . . . . . . . . . . . . . . . . . . . . . 9 16. Your Temporary Identification Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 17. If Your BIC Is Not Received, Lost, or Stolen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 18. Getting Health Care with Your BIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 19. Additional Benefits for Persons Under CHDP and EPSDT. . . . . . . . . . . . . . . . . . . 10 20. How to Get Medi-Cal Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 21. Payments for Medical/Dental Expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 22. Getting Help from Medi-Cal If You Are Out of State. . . . . . . . . . . . . . . . . . . . . . . 11 23. Medi-Cal Managed Care As Your Healthcare Provider. . . . . . . . . . . . . . . . . . . . . . . 12 24. What to Do If You Disagree with Decisions About Your Medi-Cal. . . . . . . . . . . . . . Eligibility or Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 25. What to Do If You Have Been Hurt by Another Person or Hurt At Work. . . . . . .13 26. A Deceased Medi-Cal Beneficiary’s Estate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 27. Medi-Cal Fraud. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 28. Helpful Words to Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 29. Spanish Translation of Pamphlet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 30. Traduccíon al Español del Folleto.. . . . . . . . . . . . . . . . . . . . . . . . . . . Página 16

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Medi-Cal What It Means To You 1. Medi-Cal – What it Means to You Medi-Cal pays for many health care services, including some dental services, for certain needy residents of California. Medi-Cal is supported by federal and state taxes. This pamphlet tells you how to apply, about benefits, your choices for getting services, how to use the permanent plastic California Benefits Identification Card (BIC) or the paper Medi-Cal card, and your appeal rights if you feel you are treated unfairly or do not get what you are entitled to get by law. You may be eligible for Medi-Cal benefits regardless of sex, race, religion, color, national origin, sexual orientation, marital status, age, disability, or veteran status. Your local county social services office manages most Medi-Cal eligibility determinations. You can locate the nearest county social services office in the government section of your local telephone directory or visit the Department of Health Care Services website at www.dhcs.ca.gov. The Spanish translation (traduccion al Español) follows the English section of this pamphlet. The meaning of some Medi-Cal terms and words used in this booklet is at the end of the English and Spanish sections.

2. Who Can Get Medi-Cal

Even if you are working, own a house, or are

married, you may be eligible for Medi-Cal. To get covered Medi-Cal services, you must be eligible under one of the following categories. A. Public Assistance (PA): If you are aged (age 65 or older), blind, or disabled and you get Supplemental

Security Income/State Supplementary Payment programs (SSI/SSP), you are automatically eligible for Medi-Cal and will be sent a BIC. Call your Social Security office for more information. If you get California Work Opportunity and Responsibility to Kids (CalWORKs), you may also be entitled to get Medi-Cal benefits. If you get other kinds of Public Assistance, you may be entitled to all the services covered by Medi-Cal. Call your county eligibility worker for more information. If you are not in one of these assistance groups, you still may be able to get Medi-Cal benefits in a different category. Some are listed below, such as Medically Needy or Medically Indigent. These programs are for people who cannot pay all their medical expenses. Even if you have other private health insurance coverage, you may still be eligible. B. Medically Needy (MN): You are Medically Needy

if you are age 65 or older, blind, disabled, or you meet the family circumstances required for CalWORKs (you have children under age 21 who are needy and do not have the support or care of one parent because of his/ her absence, death, incapacity, or unemployment). MN people do not get a cash grant because they have too much income or property or do not want a cash grant. You may become eligible for Medi-Cal and get a BIC by paying or promising to pay medical expenses which equal your “share of cost”(SOC) for the month. (See Sections 10 and 11.) C. Medically Indigent (MI): You are Medically

Indigent if you are a pregnant woman with no linkage (connection) to a Public Assistance program (CalWORKs); a person age 21 to 65 in a skilled nursing -1-

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or intermediate care facility; persons under 21 years of age, including those in foster care whose needs are met fully or in part by public funds; or a child who qualifies for the State-only Aid for Adoption Assistance Program. Certain other children not living with a parent or relative may also be included in the MI group. D. Special Programs:

• Pregnant Women If you are pregnant and cannot afford to pay for health care and some dental care, Medi-Cal can help pay for medical expenses for you and your unborn child. Many times you can get Medi-Cal at no cost to you, even if you have income. Once you get Medi-Cal, increases in your family’s income will not be counted during your pregnancy and postpartum period, and for your baby’s first year of life. Some Medi-Cal providers in California that offer prenatal care, can enroll pregnant women into immediate, temporary pregnancy-related coverage under the Presumptive Eligibility for Pregnant Women program pending the formal Medi-Cal application. If you are pregnant and interested in enrollment, ask if your provider participates in this program. If you need additional information, please call the Presumptive Eligibility for Pregnant Women program’s toll free number at 1 800-824-0088 or visit the website at www.dhcs.ca.gov/services/medi-cal/ eligibility/Pages/PE.aspx • Children Your child may get Medi-Cal at no-cost, if your child is an infant or, between ages 1 and 6, or between ages 6 and 18. • Refugees If you are a refugee or entrant not qualified for the MN or MI programs, ask your county eligibility worker for Refugee/Entrant Medical Assistance (RMA/EMA). • Noncitizen Victims Of Human Trafficking And Other Serious Crimes If you came to the United States as a victim of human trafficking or other serious crime, ask your -24/7/2015 11:51 AM

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county eligibility worker about the Trafficking and Crime Victims Assistance Program (TCVAP). • Confidential Medical Services Available To Persons Under Age 21 If you are under 21 years of age, unmarried, and living with your parents, you may get certain confidential medical services. Under the Minor Consent Program, you do not need parental consent to determine eligibility. Medical services included under this special program are those which relate to family planning, pregnancy, drug/alcohol abuse, sexually transmitted diseases, sexual assault, and mental health. • Former Foster Child Program You can get Medi-Cal until you reach age 21 under the Former Foster Child Program regardless of your income if you are in foster care on your 18th birthday. You are eligible even if you live with someone else, move to another county or were terminated from Medi-Cal. • Special Treatment Programs If you need dialysis treatment or parenteral hyperalimentation services, you may be eligible for for the Special Treatment programs. • Medicare Savings Programs Medi-Cal may help you pay for some Medicare expenses under a Medicare Savings Program. The Qualified Medicare Beneficiary (QMB) Program pays Medicare Part A and/or Part B premiums, copayments and deductibles. The Qualified Disabled Working Individual (QDWI) Program pays Medicare Part A premiums. The Special Low-Income Medicare Beneficiary (SLMB) and the Qualifying Individual-1 (QI-1) Programs pay for Medicare Part B premiums. • Immigrant Eligibility For Medi-Cal Immigrants who meet all Medi-Cal eligibility requirements can get full or restricted Medi-Cal depending on their immigration status. Immigrants who are not in a full scope eligible immigration status can qualify for restricted Medi-Cal, which covers emergency and pregnancy-related services, if they

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meet all eligibility requirements. Some immigrants getting restricted Medi-Cal can also get long-term care if they need it. • Breast And Cervical Cancer Treatment Program (BCCTP) BCCTP provides needed no-cost breast or cervical cancer treatment and related services to eligible persons identified by providers through the Cancer Detection Program: Every Woman Counts (EWC) or Family Planning, Access, Care and Treatment (FPACT). For more information, call toll free at 1-800-824-0088. • Other You might qualify for medical assistance in another category. Ask your county eligibility worker to help you. E. Other Services to Medi-Cal Beneficiaries:

• Additional Services Available To Persons Under Age 21 If you or your child are under age 21, you may be able to get more or different services through the Child Health and Disability Prevention (CHDP) or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) programs. This is so that children and young adults under 21 years of age can get all the health care services they need to make sure health problems are found and treated early. Regular check-ups are important so medical, dental or mental health problems are found and treated early. (See Section 19) • Medical Support Enforcement All children have the right to be supported by both parents. If you are applying for Medi-Cal benefits, you must cooperate in establishing paternity for a child(ren) born out of wedlock and obtaining medical support for a child(ren) who has an absent parent. You will be provided all child support services unless you notify the Local Child Support Agency (LCSA) that you do not want to receive those services that are unrelated to obtaining medical support and establishing paternity. Some of the available services are as follows:

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• Locating the parent(s) for support enforcement purposes; • Establishing paternity; • Establishing a child and/or medical support (health insurance) order; • Enforcing a child and/or medical support order; • Modifying an existing court order for child and/or medical support; • Enforcing a spousal support order in conjunction with a child support order, and • Collecting and distributing support payments. Note: Custody and visitation services are not provided.

3. Medi-Cal for Persons with Disabilities

; To get Medi-Cal as a person with a disability, you must have severe physical and/or mental problem(s) which will: 1. last at least 12 months in a row, and 2. stop you from working during those 12 months, or 3. possibly result in death. You must prove your disabling physical and/or mental problem(s) with medical records, tests, and other medical findings. The medical problem must be the main reason why you do not work. • 250% Working Disabled Program. Eligible working individuals with a disability can get Medi-Cal from the 250% Working Disabled Program. You must be working and earning some form of income (“work” is undefined for the purpose of qualifying for this program), have countable income below 250% of the federal poverty level and pay a premium based on your income. Disability income is not counted when determining eligibility or premium amount; however, your disability income may be affected by earning income. In order to qualify for this program – you must be determined “disabled” according to statements 1. and 3. above (you do not have to be unable to work for 12 months). For more information on the 250% Working Disabled Program, contact your county -3-

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Medi-Cal —What It Means to You

social services office or county eligibility worker. For more information on how your disability income may be affected by your earnings, contact your local Social Security Office. To get Medi-Cal for a child with a disability, the child must have severe physical and/or mental problem(s) which: 1. are on a list of disabling childhood conditions, or 2. are so severe that he/she would not be able to do daily activities which a healthy child would be able to do. When an adult or child has certain severe physical and/or mental problems, he or she may be able to get Medi-Cal based on disability prior to the final disability determination. For more information, ask your county eligibility worker about eligibility for Presumptive Disability or another Medi-Cal program.

4. Medi-Cal and Your Income You can get Medi-Cal regardless of how much money you get. However, the more money you get, the more you will have to pay or promise to pay toward your medical bills before Medi-Cal will help pay your other medical bills. (For Share of Cost information, see Sections 10 and 11). If you are disabled and working, you can pay an affordable monthly premium instead of paying a share of cost (for information on the 250% Working Disabled Program, see Section 3).

5. Medi-Cal and Your Property/Assets There are property/assets limits for the Medi-Cal program. If your property/assets are over the MediCal property limit, you will not get Medi-Cal unless you lower them according to program rules. The county looks at how much you and your family have each month. If your property/assets are below the limit at any time during that month, you will get Medi-Cal, if otherwise eligible. If you have more than the limit for a whole month, you will be discontinued. The home you live in, furnishings, personal items, and one motor vehicle are not counted. A single person is allowed to keep $2000 (or $3000 in some situations) in property/ assets, more if you are married and/or have a family. -44/7/2015 11:51 AM

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If a child has property/assets or if a stepparent wants Medi-Cal for a stepchild, other rules may apply. Important: If you or your spouse (husband or wife) went into a medical institution or nursing facility on or after September 30, 1989, and were expected to remain for 30 days while the spouse was still home, the spouse at home may keep up to $109,560 in some cases. (This amount may change in January of each year). For more information on Medi-Cal property/ assets rules, please ask your county social services office for a form called “Medi-Cal General Property Limitations”(MC Information Notice 007).

6. Proof of California Residency

You must be a resident of California to get Medi-Cal.

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You must also give evidence that you are a resident of California before your Medi-Cal can be approved. Evidence may be one of the following: 1. A recent California rent or mortgage receipt or utility bill in your name, or 2. A current and valid California motor vehicle driver’s license or Identification Card issued by the California Department of Motor Vehicles in your name, or 3. A current and valid California motor vehicle registration in your name, or 4. A document showing you are employed in California (such as a pay stub), or 5. A document showing you are registered with a public or private employment service in California, or 6. Evidence that you or your children are enrolled in school in California, or 7. Evidence that you are receiving public assistance, other than Medi-Cal, in California, or 8. Evidence that you are registered to vote in California, or Other evidence of your California residency may be acceptable if you declare that you do not have any

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of the documents or evidence listed in numbers 1 through 8 above. However, you do not have to give evidence if: 1. You are applying for Minor Consent services, or 2. You are the child of a parent who has also applied for Medi-Cal and given evidence of California residence, or 3. Your wife or husband has applied for Medi-Cal and given evidence of California residence, if she or he lives at your same address.

7. Where to Apply for Medi-Cal

& Call your county social services office to have a

Medi-Cal application sent to your home. If you want to apply in person, ask your county social services office where you can apply. Medi-Cal county eligibility workers also are located at some health clinics and hospitals. If you get an SSI/SSP grant, Medi-Cal eligibility is automatically set up by your Social Security district office (see Section 2). For more information you can call your local Social Security Administration (SSA) office, or their toll free number, 1-800-772-1213. You can also visit their website at www.ssa.gov.

8. How to Apply for Medi-Cal The usual application procedure is: 1. Call or go to your county social services office to get a Medi-Cal application. If you have an immediate need for health care services (such as severe illness or pregnancy), complete the Medi-Cal application and take it to your closest county social services office. Tell the county social services office that you have an immediate need for medical or dental care. The county social services office will process your application as fast as possible. 2. Fill out the application form(s) as completely as you can. Section 9 called “Required Documents to Apply for Medi-Cal” tells you what proof to give the county social services office when you apply for Medi-Cal. You can speed up the process by providing the necessary information and

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paperwork quickly. 3. Request Medi-Cal “retroactive coverage” if you have unpaid bills for covered medical/dental services in any of the three months before the month you apply for Medi-Cal and need help from Medi-Cal to pay the bills. To receive this coverage, you must be eligible for Medi-Cal in the month the Medi-Cal covered medical/dental services were provided. To request retroactive coverage, contact the county social services office within one year of the month in which the covered services were provided to you. For example, if you received medical/dental services any time in October 2010, you should contact the county social services office by October 31, 2011 to have a timely request. If you have already paid for the covered medical/ dental bills provided during the three months of the retroactive period, Medi-Cal may also help you get reimbursed. You must submit your claim within one year of receipt of the services or within 90 days after issuance of the Medi-Cal card, which ever is longer. For more information or to file a claim, you MUST call or write to the following: For Medical, Mental Health, Drug and Alcohol, and In-Home Support Services Claims: Department of Health Care Services

Beneficiary Services P.O. Box 138008 Sacramento, CA 95813-8008 (916) 403-2007 (916) 635-6491 TDD For Dental Claims: Denti-Cal

Beneficiary Services P.O. Box 526026 Sacramento, CA 95852-6026 (916) 403-2007 (916) 635-6491 TDD 4. When you apply for Medi-Cal, you will get a list of your rights and responsibilities. For example, -5-

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Medi-Cal —What It Means to You

you must give any changes in address, property, income, family composition, other circumstances, and private health insurance coverage to your county eligibility worker within ten days. Note: Once you apply for Medi-Cal, Medi-Cal will only pay for the covered services you get from an enrolled Medi-Cal provider. You must confirm that the provider is an enrolled Medi-Cal provider before you get services if you want Medi-Cal to pay for the services. If you’re found eligible, your case will be reviewed periodically. You must return all required information that is sent to you by the date requested in order for your Medi-Cal coverage not to be stopped or interrupted. 5. Mail or take the completed application and necessary verification (proof) to the county social services office. If you want confidential minor consent services, go to the nearest county social services office. Note: In some counties, when you are a Medi-Cal “beneficiary” (that’s what you are called when you get Medi-Cal) you may be required to sign up for a Medi-Cal health care plan and/or dental plan. If you are required to sign up for a medical or dental plan, you may choose a personal doctor and/or dentist from a list given to you by the medical and dental plans. If you live in one of those counties where there are Medi-Cal medical and dental plans, you will receive additional information about the choices you have available for getting your Medi-Cal benefits and the plans offered to you. You will receive this information at the time you apply for benefits, or when the county redetermines your benefits. In some cases, you will receive information about the medical and dental plans available, and information about how to enroll in the plans through the mail. 6. It may take up to 45 days to process your Medi-Cal application. If you apply for Medi-Cal based on disability, your application may take up to 90 days. 7. You will get a letter in the mail telling you -64/7/2015 11:51 AM

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if your Medi-Cal application is approved or denied. If you have a Medi-Cal health care plan, you will get a health care plan identification card in addition to the State-issued Benefits Identification Card (BIC). 8. If you do not get an answer to your Medi-Cal application within a month after you apply, call the county social services office.

9. Required Documents to Apply for Medi-Cal

4 You must give certain information before your Medi-Cal can be approved. Your county eligibility worker will tell you what proof is needed. You may apply without the proof, but you will have to give it later. If you cannot get the proof yourself, ask your county eligibility worker to help you. Items required for full Medi-Cal benefits (if applicable): 1. Social Security card(s). 2. Medicare card(s). 3. Proof of U.S. citizenship or U.S. national status (some citizens are exempt). 4. Alien registration card(s) or other immigration documents and identity (some groups are exempt). 5. Pregnancy verification. 6. Income verification: a. Employee pay stubs or a statement from your employer showing gross earnings and deductions. b. Award letter or checks showing amount of pension or benefits, including Social Security and Veteran’s Administration. c. State Unemployment or Disability award letter. d. Student Loan grant award letter(s) or loan grant papers. e. Statement from providers of other income (contributions, refunds, child support, etc.). f. Self-employment information: Last year’s tax return or current ledgers, current inventory, including business equipment and supplies. g. Care costs for child/incapacitated person(s). 7. Property Tax statements for all property. 8. Vehicle Registration(s) for automobiles, boats,

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campers and trailers. 9. All checking and savings account statements and trust account documents. 10. All stocks (brokerage statements), bonds (including U.S. savings bonds) and mutual funds. 11. All deeds of trust, mortgages, other promissory notes and contracts of sale. 12. All life insurance policies, including cash surrender value. 13. All annuity policies. 14. All burial trusts/prepaid burial contracts/ information on burial plots. 15. Documentation regarding the current value of all trusts. 16. Payment book(s) for all encumbered property. 17. All policies/cards for health insurance you currently have or which are available to you. 18. Application(s) for possible available income (e.g. unemployment benefits, state disability benefits). 19. Court orders relating to income and property. 20. Lease agreements. 21. Life estate documents. 22. Copies of patient trust account ledgers. 23. Rent receipts, current utility bills, or housing statement. 24. Copies of child support orders or divorce decree. 25. Social Security disability or SSI denial or discontinuance notice (if applying for disabilitybased Medi-Cal). 26. Evidence of California residency. (See Section 6)

10. When You Need to Pay a Share of Cost

m

Depending upon your monthly income, Medi-Cal may determine that you have to meet a share of cost (SOC) before Medi-Cal will pay for your or your family’s medical expenses for the month. The next section explains “meeting a share of cost.” Whether you will have a SOC for a month, and the size of your SOC, depends on how much money or income you and your family get for the month. Medi-Cal allows you to keep a certain amount of your family’s income for your living expenses (this portion is called your Maintenance Need). Medi-Cal may also allow you to

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keep additional amounts of your family’s income. Any income for the month which is more than the amount you are allowed to keep becomes your SOC for the month. In some families, the income of one person cannot be used to decide if another person has a SOC. For example, income of a child cannot be used to decide whether a brother or sister, parent, stepparent or caretaker relative has a SOC. Income of a stepparent cannot be used to see if a stepchild has a SOC. If you don’t have any medical expenses during a month, you do not need to meet your SOC for that month. However, keep your Benefits Identification Card (BIC) in case you need medical services in upcoming months.

11. How to Meet Your Share of Cost You may meet your Share of Cost (SOC) for the current month by showing Medi-Cal that you paid, or have promised to pay, for your medical expenses (including dental) an amount of money the same as your SOC. There are two ways to show Medi-Cal that you have paid or promised to pay your SOC for a certain month. These two methods are: 1. In every month that you have a SOC, your county social services office will notify the State of the amount of SOC you must pay. When you go to a medical provider and give the provider your BIC, your provider will get information from a computer system about your SOC. After the provider accepts your promise to pay for the medical services, or you pay for those services, the provider will forward the amount of SOC paid, or promised to be paid, through the computer system to the State. The State will immediately update the SOC system so that future providers that month will know the amount of SOC that remains, if any. When you have met your SOC for the month, all future providers will receive information that you have met your SOC for the month and whether or not you are eligible for covered Medi-Cal services. -7-

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2. Another way to show you have paid or promised to pay your SOC is to give your medical bills directly to your county eligibility worker. You may give your bills for medical services you got during the current month to your county eligibility worker to apply toward your SOC. You must give old medical bills from previous months (for which you still owe money and which you want to apply toward your SOC) to your county eligibility worker. Your provider cannot use the SOC computer system for your old medical bills. Medical bills given to your county eligibility worker must contain certain kinds of information before your county eligibility worker can apply these bills toward your SOC. Your medical bills must show this information: a. Provider’s name, address, Medi-Cal provider number, or if not a Medi-Cal provider, the provider license number, or federal tax identification number. b. Name of person who got the medical service. c. Description of the medical service received. d. Procedure Code (a medical/dental reference number) for medical/dental services received – your provider will know what this number is. e. Date(s) medical service was received. f. Date on which the bill was issued. For old medical bills, this date must be within 90 days of the date you give the old medical bills to your county eligibilty worker. g. Amount billed to person getting the service. If any of this information is missing from a medical bill, you must try to get it from your provider. If you are unable to get it, your county eligibility worker will try to help you. Billing statements from collection agencies and credit card statements sometimes may be used as evidence of medical expenses. Under certain conditions, you may give the missing information by making a sworn statement. If your county eligibility worker is unable to accept a medical bill, you will get a letter giving the reason for the disapproval of the bill. You will have ten days to -84/7/2015 11:51 AM

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fix the problem and bring/send the bill again. If you do not do this, you will receive a denial letter within the next 30 days which will give the reason for the denial and tell you what you must do before you may resubmit your medical bill. You will get a separate letter for medical bills which have been accepted and applied toward your SOC.

12. Private Health Insurance and Medi-Cal You can have Medi-Cal even though you have Other Health Coverage (OHC) through individual or group private health (or dental) insurance coverage. If you are a Medi-Cal beneficiary and have individual or group private health (or dental) insurance coverage, you are required by federal and state law to report it. You can report it directly to Department of Health Care Services (DHCS) by sending it via e-mail to [email protected] or via fax (916) 440-5675. You can also report it to your county eligibility worker, your health care provider, and/or to the Local Child Support Agency (LCSA), when there is an absent parent who may be responsible for your child(ren)’s medical care, or in establishing paternity of a child born out of wedlock. If you fail to report any private health insurance coverage that you have, you are committing a misdemeanor. Under federal law, private health insurance belonging to a Medi-Cal beneficiary must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including OHC co-payments, OHC co-insurance and OHC deductibles. Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC payment amount, if any. Medi-Cal will not pay the balance of a provider’s bill when the provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as payment in full. The MediCal provider must submit an Explanation of Benefits or denial letter from the OHC along with the Medi-Cal claim. If Medi-Cal later discovers OHC, Medi-Cal will bill the OHC for the Medi-Cal services. If you have a Medi-Cal share of cost you must pay it before Medi-Cal will pay for your service. If your other health insurance is a Prepaid Health Plan (PHP) or a Health Maintenance Organization (HMO), you must use the plan facilities for

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regular medical care (non-emergency services). Send any payment you get directly from an insurance carrier for services paid by Medi-Cal to DHCS at: Department of Health Care Services

Third Party Liability and Recovery Division Cost Avoidance Section P.O. Box 997424, MS 4719 Sacramento, CA 95899-7424 Send any medical support payment you get from the absent parent to DHCS at this address: Department of Health Care Services

Third Party Liability and Recovery Division Cost Avoidance Section P.O. Box 997422, MS 4719 Sacramento, CA 95899-7425 If you have other health insurance coverage, the computer system will be coded to show other health insurance. If this information is incorrect you can contact your county eligibility worker to temporarily override this information. The correct information then needs to be reported to DHCS. To correct this information, e-mail DHCS at [email protected] or send a fax to (916) 440-5675. If you are having a claims payment problem with a provider, you may call the Beneficiary and HIPAA Privacy Help Desk at (916) 636-1980. Note: Beginning January 1, 2006, if you are a recipient of both Medicare and Medi-Cal, Medicare (not Medi-Cal) will pay for most prescription drugs for Medi-Cal beneficiaries who are eligible for Medicare Part A (hospital) or Part B (outpatient). For information on Medicare Part D (drug coverage), please contact 1-800-MEDICARE (1-800-633-4227).

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program and not all applicants are approved for HIPP. For more information on HIPP: • ask your county eligibility worker to refer you, or • call the DHCS’ HIPP Program at 1-866-298-8443 (toll-free) or • visit their website at www.dhcs.ca.gov or • send an email to [email protected] or • send a fax to (916) 440-5676. A HIPP representative in Sacramento will explain the process and requirements for the program. If it appears that you may meet the eligibility requirements, an application will be sent to you.

14. The Medi-Cal Identification Card Medi-Cal mails plastic Benefits Identification Cards (BICs) to all beneficiaries. The 14 numbers and letters on your card identify you. Your health care providers need your BIC to provide services and to bill Medi-Cal. If you have an “Immediate Need” or get Confidential Medical Services (Minor Consent) as described in Section 2D, your county social services office will give you a paper Medi-Cal card. Note: Your BIC does not guarantee Medi-Cal eligibility. Take your BIC or paper card to your doctor, dentist, pharmacy, hospital or other medical provider. The provider will use this card to verify that you are eligible for Medi-Cal.

15. What the Benefits Identification Card (BIC) Looks Like A BIC looks like this:

13. Medi-Cal May Pay Private Health Insurance Premiums If you are a Medi-Cal beneficiary and you have a very high-cost medical condition which requires a physician’s care, the DHCS may pay your private health insurance premiums, if it is cost effective, under the Health Insurance Premium Payment (HIPP) program. There are specific requirements to qualify for the

Actual card size = 3-1/8”x 2-3/8”; white card with blue letters on front, black letters on back. Beneficiary Information on face of card: q Your ID Number (a 14 character Identification number) -9-

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w Your name e Gender Code (male or female) r Date of Birth t Date card was issued to you If the card you got in the mail has wrong information on it contact your social services office.

16. Your Temporary Identification Card Your paper identification card will show your name, Medi-Cal identification number, gender, date of birth, issue date and good through date. “Immediate Need” cards are issued for a one month period and Minor Consent cards are issued for up to a year. Note: If you are a beneficiary 18 years of age or older who is not in long-term care, and not getting emergency services, you must sign and date your paper Medi-Cal card or BIC when you get it and before you give the paper Medi-Cal card or BIC to a provider for any care.

17. If Your BIC Is Not Received, Lost, or Stolen You may ask for a BIC from your county social services office when you are eligible for Medi-Cal, if you have not gotten a card, you lost your card, or your card was stolen. If your BIC is stolen, you must tell your local police and your county social services office. You should give as much information about the theft as possible. If you are issued a new card, then your old card will no longer be valid. If you get SSI/SSP, even though the county does not make SSI/SSP eligibility determinations or send SSI/ SSP checks, they help with BIC problems for people who get SSI/SSP. The county can order a replacement BIC for you. The county social services office will tell you if you also need to contact a Social Security office to correct the problem with your BIC.

18. Getting Health Care with Your BIC

 You should always carry your BIC with you.

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takes Medi-Cal patients before you go for treatment. The provider has a right to refuse to take Medi-Cal. If you forgot to tell the provider that you have Medi-Cal, you may have to pay your medical bill out of your own pocket. About receiving your services: • Ask your local medical society for providers who take Medi-Cal patients. • Call the Delta Dental office for dental referrals at 1-800-322-6384 for referrals to Medi-Cal dental providers. • For each service you get, give the provider your BIC so Medi-Cal can pay the provider (if you are eligible for Medi-Cal). • Some services must be approved by Medi-Cal before you may get them. The provider will know when you need prior approval. • Some services are restricted. • Some doctor's services and clinic visits may be limited. • You should discuss your treatment plan and appointments with your doctor. • Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services do not require prior approval. However, these services may be limited.

19. Additional Benefits for Persons Under CHDP and EPSDT If you or your child is under 21, the Child Health and Disability Prevention (CHDP) program provides regular check-ups and needed immunizations to keep you healthy. CHDP services include regular screening for medical, dental, vision, hearing or mental health problems. If you need help with an appointment or transportation, the CHDP program in your county can help you. Look for the phone number under county government in your local phone book. The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program provides extra Medi-Cal services if you are under 21 and have full scope Medi-Cal. EPSDT services correct or improve medical, dental, or mental health problems. You may get the extra services if you and your doctor, health care provider, clinic,

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county CHDP or county mental health department agree you need them. You can ask for services as often as you think you need them. If you have severe emotional problems, contact your county mental health department. Look in the government section of your phone book under Mental Health Department. If you cannot reach the county mental health department, call the state mental health ombudsman toll-free at 1-800-896-4042. If you, your doctor or dentist thinks that health services which are not usually covered by Medi-Cal may be needed, you should talk to: • Your local county CHDP Program • Your Managed Care Plan • Your County Mental Health Department Or ask your doctor or dentist to contact: • Your local Medi-Cal Field Office, or • The California Children’s Services program

20. How to Get Medi-Cal Services How you get your Medi-Cal services will depend on the area you live in. In some areas, you may choose your providers from those who accept Medi-Cal, or you may choose to sign up for a Medi-Cal health and/ or dental care plan if there are any in your area. In other areas, some Medi-Cal beneficiaries must sign up for a health and/or dental care plan. In the areas where you must sign up for a health care plan, there are exceptions. The exceptions will be explained to you at the same time your choices for getting Medi-Cal services are explained to you. You will get information about health/dental care plans at the time you apply or reapply for benefits. You may be required to go to a presentation at the county social services office where they tell you about the health care plans you can sign up for. You may also get information in the mail about the health care plans in your area. There are two ways to get your Medi-Cal services: 1. In those areas where you can choose your own providers, you should know how to use the Benefits Identification Card (BIC) before you see a doctor or other provider of health services. Please read

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Sections 16 and 18. If you are not enrolling in a health care plan and choosing your own providers, you must tell the health care provider that you have Medi-Cal before you first get care. If you do not tell the provider that you have Medi-Cal, the provider may legally bill you for all services you get. Providers of health care do not have to take Medi-Cal patients or may only take a few MediCal patients. If you don’t use your BIC card correctly, you may have to pay for the services you get. 2. If you sign up for a Medi-Cal health/dental care plan, you may choose a provider from a provider list the plan gives you. As a plan member, you can get all of the services covered by regular Medi-Cal. Some plans offer extra services which you cannot get with your BIC card.

21. Payments for Medical/Dental Expenses

m Your BIC will pay for many kinds of medical/

dental expenses. When your provider uses your BIC to verify your Medi-Cal eligibility, your provider will know if Medi-Cal will pay for a medical/dental treatment or if you need to make a “co-payment” for any treatment. You may have to pay a co-payment when you get medical/dental services, a prescribed drug, or if you go to the hospital or emergency room. Note: If you have Medi-Cal and Medicare, Medicare (not Medi-Cal) pays for most of your prescribed drugs.

22. Getting Help from Medi-Cal If You Are Out of State Take your BIC or proof of enrollment in a Medi-Cal health care plan with you when you travel outside California. Medi-Cal can help in limited situations; for example, in an emergency due to accident, injury, or severe illness, or when your health would be endangered by postponing treatment until you return to California. Medi-Cal must first approve any outof-state in-patient medical services before you get the service. You will be responsible for medical costs for services you got out-of-state if the medical provider is not a Medi-Cal provider or does not wish to become a Medi-Cal provider. - 11 -

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The provider should first verify eligibility by contacting the fiscal intermediary at (916) 636-1960. The provider may get information on coverage, authorization and billing procedures by contacting the following: Medical Services Department of Health Care Services

Medi-Cal Field Office P.O. Box 193704 San Francisco CA 95670-3704 (415) 904-9600 Dental Services Denti-Cal

Delta Dental 1155 International Drive, Building C Rancho Cordova, CA 94119 1-800-423-0507 If you live near the California state line and use doctors or other providers of medical service in the other state, some of these restrictions do not apply. However, medical services in Mexico or Canada are not covered except for emergency hospitalization. You will not get Medi-Cal if you move out of California. You may apply for Medicaid in the state in which you live.

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1-800-430-4263 for more information about your health plan choices. • How to Get Out Of a Managed Care Plan If you live in a Two-Plan Model or Geographic Managed Care county, and the option to join a health care plan is voluntary, you may disenroll at any time. (To disenroll, contact the plan membership staff at the phone number provided in the papers you got when you signed up). If you have questions about your Two-Plan Model or Geographic Managed Care health plan, you can call Health Care Options at 1-800-430-4263. If you are not disenrolled in 45 days, contact your county eligibility worker for help.

24. What to Do If You Disagree with Decisions About Your Medi-Cal Eligibility or Benefits

.

You have the right to ask for a State hearing if you do not agree with a county or State action or inaction about your application for Medi-Cal, changes to your Medi-Cal eligibility, or denial of a health benefit.

Medi-Cal Managed Care is a program whereby the State contracts with various health plans to provide services for you in an organized and coordinated manner. The managed care plans must directly give, or arrange for, all Medi-Cal services to you.

You will get a Notice of Action (NOA) that tells you the county or State decision about your Medi-Cal eligibility. If you disagree with a county or State decision, you can talk to your county eligibility worker and/or request a State hearing. You must request the State hearing within 90 days from when the NOA was mailed or given to you. If you do not receive a NOA you must ask for a State hearing within 90 days from the date on which you found out about the action you disagree with.

• Which Providers to Go to When Enrolled In a Health/Dental Care Plan If you enroll in a health/dental care plan, you must use the plan providers and clinics unless emergency care is needed.

If you ask for a State hearing before the effective date of the action, you may continue to get the same MediCal benefits until the hearing decision. Your benefits may stop or be lowered if you cancel your request for a State hearing.

• How to Join a Managed Health Plan You can ask your county eligibility worker if managed care is available and how to contact either the health care plan or the local health care options worker. Or contact Health Care Options (HCO) at

You may ask for a State hearing through the county social services office or the California Department of Social Services. On the back of the NOA, you will find out how you can request a State hearing and where to send your request. If you do not have a NOA you can

23. Medi-Cal Managed Care As Your Healthcare Provider

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call or write to: California Department of Social Services

Public Inquiry and Response PO Box 944243, M.S. 19-37 Sacramento, CA 94244-2430 1-800-952-5253, 1-800-952-8349 TDD (916) 229-4110 (fax)

You must go to the State hearing or give written notice for someone to go in your place and represent you. You or your representative can read the regulations about the Medi-Cal program and most of the facts in your case. Call your county social services office to arrange for this review. Help is available in your language. At the State hearing, you may bring witnesses that know the facts about your case. You may ask questions of the county representative or any County or State witness. Discrimination: If you believe a decision about your right to get Medi-Cal benefits was unfairly made because of your sex, race, religion, color, national origin, sexual orientation, marital status, age, disability or veteran's status, you may file a written or telephone complaint with the Department of Health Care Services, Office of Civil Rights, MS 0009, P.O. Box 997413, Sacramento, CA 95899-7413, (916) 440-7370, (916) 440-7399 TDD or (916) 440-7395 (fax). Your complaint of discrimination will be investigated.

25. What to Do If You Have Been Hurt by Another Person or Hurt At Work If another person hurts you or you are hurt at work, you may use your BIC to get services. If you file an insurance or workers’ compensation claim, or sue someone for damages because of your injury, you must notify Medi-Cal within 30 days of filing your claim or action, so the liable party can pay for your treatment. Notifying your county eligibility worker is not sufficient notification, but your county eligibility worker may direct you to the web pages mentioned below. If You File a Workers’ Compensation Claim… Please contact the Medi-Cal Workers’ Compensation Program. The current program contact information

Bid 017-C003095-GH Department of Health Care Services

is available online at: www.dhcs.ca.gov/services/Pages/TPLRD_WC_ cont.aspx If You Sue Someone or File Any Other Kind of Claim for an Injury… Please contact the Medi-Cal Personal Injury Program. Using the program’s online referral form for beneficiaries is the fastest way to refer a new case or provide updates on existing cases. The current program web page for links to online forms is available online at: www.dhcs.ca.gov/services/Pages/TPLRD_ PersonalInjuryProgram.aspx A Personal Injury First Inquiry Letter (DHCS 6198) is automatically generated for some provider claims which include diagnosis codes that relate to an injury. If you receive a DHCS 6198, returning a completed DHCS 6198 to Medi-Cal is acceptable notification. If you received a DHCS 6198 and are not filing a claim or taking action for an injury, you may disregard the letter. If you hire an attorney to represent you for your claim or lawsuit, your attorney must also notify Medi-Cal and provide a letter of authorization so that Medi-Cal staff can talk with the attorney about your case. Although Medi-Cal does not provide representation nor attorney referrals, the Medi-Cal staff can provide information that can help an attorney work your case. If you have questions about the Medi-Cal Personal Injury Program, call (916) 650-0490.

26. A Deceased Medi-Cal Beneficiary’s Estate Medi-Cal may claim against the beneficiary age 55 or older for certain services received. An estate may also be billed if a beneficiary was a resident of a nursing facility, regardless of the beneficiary’s age. • Medi-Cal will not recover from an estate if the beneficiary is survived by a child under the age of 21 or a child of any age that is blind or disabled (as defined by the federal Social Security Act). • Medi-Cal will defer recovery from the estate during the lifetime of a surviving spouse or - 13 -

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Medi-Cal —What It Means to You

registered domestic partner. • Medi-Cal may waive recovery from an heir’s proportionate share of the estate claim if the heir can demonstrate that recovery will result in a substantial hardship. • Medi-Cal may impose a lien upon the beneficiary’s principle residence if the beneficiary is placed in a medical facility (such as nursing home) with no intent to return to the principle residence. The party handling the beneficiary’s estate must give written notice of death and a copy of the death certificate, within 90 days of the date of death, to the Director of the Department of Health Care Services (DHCS) at: Department of Health Care Services

Estate Recovery Section MS 4720 PO Box 997425 Sacramento, CA 95899-7425

27. Medi-Cal Fraud

d

If you are getting treatment from more than one doctor or dentist, you should tell each doctor/dentist about the other doctor(s)/dentist(s) giving care to you. It is your responsibility not to abuse or improperly use your Medi-Cal benefits. It is a crime to: • allow others to use your Medi-Cal benefits, and • get drugs through false statements. It is a crime for you to sell or lend your BIC to any person or furnish your BIC to anyone other than your provider of services as required under Medi-Cal guidelines. Misuse of BIC/Medi-Cal benefits is a crime that could result in administrative action or criminal prosecution. If you suspect someone of misusing Medi-Cal benefits, you may make a confidential report to: 1-800-822-6222 (toll-free).

28. Helpful Words to Know 1. Beneficiary – A person who has been determined eligible for Medi-Cal. 2. (Medi-Cal) Health Care Plan – The DHCS contracts with prepaid health plans, health maintenance organizations, and primary care - 14 4/7/2015 11:51 AM

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case management system to give covered MediCal services to Medi-Cal beneficiaries. Medi-Cal beneficiaries who enroll in a plan are guaranteed access to a full range of quality health care, including preventive medical services. 3. Home And Community-Based Care Services – Health care services that can sometime be given at home to persons who usually would need to stay in a hospital or nursing home. These services are only available to certain people getting Medi-Cal who meet special requirements. Ask your doctor or hospital discharge planner to contact the local Medi-Cal Field Office if you think you might need these services. 4. Inpatient Hospital Care – Care you get when you are admitted to a hospital. In some areas of the State, you can only get inpatient care at hospitals contracting with the State. If you need care, you should contact your doctor, and if necessary, your doctor will make arrangements for hospitalization. In a life-threatening emergency, or if you are a pregnant woman in active labor, any hospital can give you care. 5. Linkage – Persons who meet the federal definition of age (65 years or older), blindness, or disability, or parents and their children who are deprived of parental support or care are considered “linked”(or connected) to one of these categories. 6. Maintenance Need – The amount of monthly income Medi-Cal has determined that a person or family need for food, clothing, housing, etc. The amount will change with the number of people in the family. 7. Medi-Cal – California’s name for Medicaid, the federal and state program of medical assistance for needy and low-income persons. 8. Medicare – A federal health insurance program administrated by the Social Security Administration which is available regardless of income. Most persons 65 years of age or older and certain disabled or blind persons regardless of age, are covered. Medicare Part A covers hospitalization. Medicare Part B covers doctor bills. Beginning

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January 1, 2006, Medicare Part D (not Medi-Cal) covers most prescribed drugs. A Medicare card is red, white, and blue. 9. Medicare Premium Payment Program (Buy-In) – Medi-Cal may pay the Medicare Part A and/or Part B premiums if you have Medicare and Medi-Cal coverage. You are “Medi/Medi” eligible if you have both Medicare and Medi-Cal coverage. If you are eligible for a Medicare Savings Program such as Qualified Medicare Beneficiary (QMB), Qualified Disabled Working Individuals (QDWI), Specified Low-Income Medicare Beneficiary (SLMB), and the Qualifying Individual-1 (QI-1), you may also qualify for Medi-Cal payment of Medicare Part A and/or Part B premiums. 10. Other Health Care Coverage – Any private health benefit plan or health insurance coverage (whether individual or through a union, group, employer, or organization) under which payment can be made for health care services provided to the persons covered by that policy or plan. 11. Personal Property – All liquid and non-liquid assets (other than real property) such as cash,

Bid 017-C003095-GH Department of Health Care Services

savings accounts, checking accounts, stocks, bonds jewelry, boats, life insurance policies, recreational vehicles, etc. 12. Property Reserve – The total net market value of countable property assets of those persons applying for Medi-Cal. 13. Real Property – Land and improvements which generally include any immovable property attached to the land and any oil, mineral, timber or other right related to the land. 14. Share Of Cost (SOC) – The amount you must pay or promise to pay each month toward the cost of your health care before Medi-Cal will pay. Your SOC may change when your monthly income changes. You only pay a SOC in a month when you get health care services. A SOC is not a monthly charge that you must pay whether or not you have medical bills. 15. Verification – Acceptable evidence (documents) which gives proof of statements made by an applicant/beneficiary.

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What is WIC? The Women, Infants, and Children (WIC) Supplemental Nutrition Program is for women who are pregnant or breastfeeding, or who have had a recent pregnancy loss; and for children under 5 years old.

WIC offers families at no cost:

Checks to buy healthy foods Nutrition and health information Referrals to health care and other community resources Breastfeeding support

Number of Persons Family Unit Annual 2 $29,101 3 $36,612 4 $44,123 5 $51,634 *Income guidelines change annually.

To learn more and see if you qualify, visit: www.wicworks.ca.gov

1-888-WIC-WORKS (1-888-942-9675)

wic CALIFORNIA

WOMEN, INFANTS & CHILDREN

Families grow healthy with WIC

This institution is an equal opportunity provider. Migrants and working families are welcome to apply!

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WELCOME TO MEDI-CAL In Orange County, most Medi-Cal services are provided by CalOptima, a managed care system created by the County. In most cases, CalOptima coverage begins the month following the month of approval (date noted on the Notice of Action). If you are approved for Medi-Cal late in the month, CalOptima coverage will begin the 2nd month after the approval date. CalOptima will send you a Welcome Packet within 10-days of becoming a CalOptima member. For more information, please refer to the “CalOptima Manages Your Medi-Cal Benefits in Orange County” flyer found in the Medi-Cal information packet. If you need medical services before you are covered by CalOptima, you can receive services under the Medi-Cal Fee-for-Service system. If you are currently being treated by a medical provider, ask if he/she is a Medi-Cal provider. You may be able to continue to see the same medical provider. Present your Benefits Identification Card (BIC) to pay for the medical services you received. The card is activated when it is sent to you and eligibility can be electronically verified by the provider. If you already paid for medical services before you received your BIC, present your BIC and ask the provider to bill Medi-Cal and give you back the money you paid. Below are some answers to common questions about how to get services before you are covered by CalOptima: 1. What is fee-for-service? Fee-for-service Medi-Cal requires providers to send payment claims to the State for services provided. 2. What do I do if I need to see a doctor? You can contact any doctor you want and ask if they accept Fee-for-Service MediCal. On the back of this flyer is a list of community clinics that accept fee-for-service Medi-Cal. Whenever possible, call to schedule an appointment. 3. How do I get my prescription filled? You may take the prescription to any pharmacy that accepts Medi-Cal. Most major pharmacies accept Medi-Cal. Always call first, to make sure that your Medi-Cal coverage will be accepted. 4. What if I have an emergency, can I go to the nearest emergency room or call an ambulance? Medi-Cal coverage includes emergency services. In the event you have an emergency call 911 or go to the nearest hospital.

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CLINIC

AltaMed - Anaheim Lincoln Dental AltaMed - Anaheim Lincoln (Adults Only) AltaMed - Anaheim Lincoln West (Children Only) AltaMed - Garden Grove Harbor (Adults & Children) AltaMed - Huntington Beach Community Clinic (Medical & Dental) AltaMed - Santa Ana Broadway (Children Only) AltaMed - Santa Ana Central (Adults & Children) AltaMed - Santa Ana Main (Adults & Children) AltaMed Dental Group Community Care Dental Center AltaMed Orange Chapman (Children Only) Birth Choice Health Clinics Mission Viejo (Adults Only) Birth Choice Health Clinics Santa Ana (Adults Only) Birth Choice Health ClinicsOrange (Adults Only) Birth Choice Health ClinicsPlacentia (Adults Only) Camino Health Center (Adults & Children) Center for Inherited Blood Disorders (CIBD) (Adults & Children) Central City Community Health Center (Adults & Children)

Central City Community Health Center (Adults & Children) CHOC at the Boys and Girls Club of Santa Ana (Children Only) CHOC Clinic at Costa Mesa (Children Only) CHOC Clinic at Orange (Children Only) CHOC Clinic Garden Grove (Children Only)

CITY

Anaheim Anaheim Anaheim Garden Grove Huntington Beach Santa Ana Santa Ana Santa Ana Huntington Beach Orange Mission Viejo Santa Ana Orange Placentia San Juan Capistrano Orange Anaheim

Stanton Santa Ana Costa Mesa Orange Garden Grove

County of Orange

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ORANGE COUNTY COMMUNITY CLINICS

Orange

La Habra

La Habra

Santa Ana

(714) 638-5990

(714) 638-5990

(562) 690-0400

(562) 690-4002

(714) 289-4800

The Gary Center

SOS-EL SOL Wellness Center St. Jude Children's Dental Clinic St. Jude Neighborhood Health Center (Adults & Children)

Garden Grove

Santa Ana

Anaheim

La Habra

La Habra

Fullerton

Buena Park

Santa Ana

(714) 267-2111

(714) 418-2040

(714) 480-2490

(714) 456-7002

(562) 691-3263 , Ext 126

(714) 446-5100 (562) 691-3263 , Ext 101

(714) 552-8723

(949) 270-2160

PHONE

Garden Grove

(949) 515-6725

Santa Ana, Fullerton, Costa Mesa, Anaheim

(714) 503-0772

CITY

Costa Mesa

The Gary Center - Dental Clinic UCI Family Health Center Anaheim (Adults & Children) UCI Family Health Center-Santa Ana (Adults & Children) VNCOC Southland Health Center (Adults & Children)

Buena Park

(949) 240-2272

CLINIC

Tustin

(714) 247-0300 (714) 605-6550 (Appointments) (714) 771-8006 Medical (949) 494-0761 , x100

Exact location varies

(949) 240-2272

PHONE

Laguna Beach

(562) 493-4466

Exact location varies

(714) 532-7571

CITY

Clinica CHOC Para Ninos (Children Only) Friends of Family Health Center Adults Friends of Family Health Center Pediatrics Healthy Smiles for Kids of OC Smile Clinic at CHOC

Los Alamitos

(714) 248-9500

Locations vary

(714) 240-2066

CLINIC

(888) 499-9303 Healthy Smiles for Kids of Orange County

Stanton

(714) 368-1521

Birth Choice - Mobile Unit Buena Park Community Clinic (Mobile Unit) Camino Diabetic Mobile Medical Unit Camino Health Center - Mobile Medical Unit

Huntington Beach Visits Anahheim, Santa Ana, Orange, Brea, San Juan Capistrano, Tustin, Garden Grove, Costa Mesa, Fullerton

(714) 744-8801

PHONE

(888) 499-9303 Hope Clinic (Children Only) Hurtt Family Health Clinic (Adults & Children) KCS Health Center (Adults Only) La Amistad Family Health Center (Adults Only) Laguna Beach Community Clinic (Adults & Children) Lestonnac Free Clinic - Los Alamitos (Adults Only)

Tustin

(714) 633-4600

CHOC Breathmobile

Exact location and time vary

(714) 446-5100

(714) 289-4840

(714) 898-2222

(714) 490-2750

(714) 200-1203 (Admin)

(949) 240-2272

(714) 524-5545

(888) 499-9303

(714) 500-0400

(888) 499-9303

(888) 499-9303

(714) 919-0280

(888) 499-9303

(888) 499-9303

(714) 399-0487

(949) 364-3928

Lestonnac Free Clinic - Stanton

Orange

(714) 248-9500

Healthy Smiles - (Smile Mobile)

Exact location varies

(714) 446-5100

(714) 289-4870

North OC County Regional Health Foundation (Adults & Children) Serve The People Community Health Center (Adults & Children)

Lake Forest

Fullerton

Fullerton

Santa Ana

(949) 270-2100

(949) 609-8199

(714) 870-0550

(714) 870-0717

Orange

Buena Park

(714) 571-0588

Stanton

(714) 898-8888

HURTT Family Mobile Clinic

Brea

(714) 456-7002 Costa Mesa

MOBILE UNITS:

(714) 516-9045

Garden Grove

(714) 441-0411

Puente a la Salud Mobile Clinics

Exact location varies

Sierra Health Center (Adults Only) Sierra Health Center for Children SOS & Peace Center Health Clinic SOS Community Health Center (Adults Only)

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(714) 638-5990

Lestonnac Free Clinic - Tustin Lestonnac Free Clinic (Adults & Children) Livingstone Free Clinic (Adults & Children) Nhan Hoa Comprehensive Health Center (Adults & Children)

Fullerton

(714) 352-2911

St. Jude Mobile Family Health Clinics (2) St. Jude Mobile Family Health Clinics (I) UCI Family Health Center Mobile Van (714) 289-4851 (714) 532-7908

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County of Orange

ELECTRONIC NOTIFICATION OPTION



What is E-Notification? If you are receiving or approved for the CalWORKs, CalFresh, or Medi-Cal program, you can receive most of the county notifications electronically.



How do I sign up?

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1. To access your information and register for E-notification, you must first create a secure online account at https://www.mybenefitscalwin.org. If you already have a My Benefits CalWIN account, simply log on and click on a new hyperlink, “Why wait for the mail?” 2. You can sign up for e-Notification by signing the online agreement, “Electronic Notification Agreement” (NA 1273) through the online system (My Benefits CalWIN) if you currently receive or when you apply for CalWORKs, CalFresh, or Medi-Cal programs. 3. You will receive an email alert in your personal email account when a new notice is available for viewing in your My Benefits CalWIN Portal account. 4. The notices will remain accessible to you for six months from the date of generation. 5. You can view, print and/or save your notices. 

Can I get a paper copy of the e-notification posted in my secure online account? Yes, you can choose to receive notification both electronically and in hard copy.



Can I stop receiving e-notification? Yes. You can switch back to traditional paper correspondence at any time by updating your settings in My Benefits CalWIN, or contacting the county. F063-19-976 E-Notification Flyer (9/14)

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Approved with changes: 5-5-14 MC

Health Guide for Pregnant Women Get Prenatal Care

Learn Why You Should Breastfeed

If you think you are pregnant see your doctor right away. Those who have early and constant prenatal care have babies with better health.

Breast milk is the perfect food for your baby. It can help protect your baby from infections and diseases. It also improves brain growth for your baby!

Eat Healthy & Take Needed Supplements

Know Danger Signs

Food you eat is the main source for your baby to grow. Prenatal vitamins provide folic acid, calcium, and iron to keep you both healthy. Iodine supplements help your baby’s brain develop. Take care of your oral health. See your dentist to protect both your teeth and gums.

Watch for signs that something is wrong. Some pregnancy danger signs:

Keep Active & Maintain a Sleep Routine Exercise can give you a good sense of well-being. Ask your doctor how much is safe for you. Do not overdo it. Try to sleep and wake up at the same time. Rest and nap in the day as you need.

• • • • • • • •

Bad stomach pain or cramps Throwing up often or nausea Fever or chills Severe or sudden headaches Swelling of face or hands Vision change (blurred, seeing spots, flashes) Bleeding or cramping Your baby is moving less than normal

Tip: Always talk to your doctor right away if you have any questions or concerns. Get Your Vaccines & Avoid Health Risks

Take Care of Yourself

Protect both you and your baby from diseases. Ask your doctor about getting your flu and pertussis booster shots. Learn how to avoid foodborne illness such as listeria and salmonella. Find out how to avoid health hazards such as cat litter and cleaning sprays.

Many women feel intense sadness, feel more anxious, or have mood swings during or after being pregnant. It is not your fault if you feel this way. There are safe options to help you.

If you need help to make or get a ride to your doctor, call the Health Network number on your health ID card. They will work with you to get the care you need.

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Before Your Baby Arrives

• Make home safe for your baby. Take action by checking the safety of where your baby sleeps. Keep emergency numbers near phones. • Check that you have basics to care for your baby. Many products may overwhelm you. Remember your baby really only needs food, shelter and you. • Find your baby a doctor a few months before your due date. • Learn about baby care by attending a newborn class or searching online. • Take care of last minute to-do’s. Make a birth plan, pack a bag for the hospital and take time off work. • Infant car seats save lives. Your infant car seat should meet current safety standards. Check that it is properly installed. You will need your infant car seat when you deliver your baby.

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Now That Your Baby Has Arrived • Remember Safe to Sleep®. Always have your baby sleep on their back. Do not use blankets, pillows, or bumpers. Never sleep in the same bed with your baby. • For the first 6 months try breastfeeding your baby without giving other liquids such as formula or water. Begin solid foods at 6 months. You can continue to breastfeed through the first year and beyond. • Make an appointment with your baby’s doctor for their first newborn health check-up. • Protect your baby by getting vaccines on time! Your baby needs important vaccines at baby’s 2-month, 4-month and 6-month checkups. • Take care of your needs after birth. Do not forget to schedule your postpartum check-up. Eat healthy and rest. Get help right away if you feel sad, anxious or depressed. • Plan for your health. Getting pregnant soon after birth can be risky to you and your baby.

More Resources: Healthy Children.org www.healthychildren.org Orange County Behavioral Health Information and Referral Line 855-OC-LINKS (625-4657)

Orange County Perinatal Council In association with Orange County Health Care Agency 4/7/2015 11:51 AM

March of Dimes www.marchofdimes.com/pregnancy.aspx text4baby Text BABY to 511411 for FREE messages Womens Health.gov www.womenshealth.gov

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13

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Req # 1064941 MC Walk-In English April 2015 Region

Quantity

ARC

1,175

AVRC

1,700

CRO

100

MSRC

200

OCPC

575

SARC

1,050

TASK FORCE

10,000

Total

14,800

Staple Top Right Corner

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Question and Answers for Bid #017-C003095-GH - Social Services Agency Medi-Cal Walk-In Packets

5

Overall Bid Questions Question 1 On Attachment B - 1) Pricing you ask for Tax but the pricing page we are to submit does not ask for tax. Shouold I include tax or not and I would think the tax is only on paper not services? (Submitted: Apr 7, 2015 10:32:48 AM PDT) Answer - Attachment B is an example of what's included on the contract for the winning bidder. Pricing that's provided for the bid is before taxes, unless the bidder specifies so. And commodity is taxed and not services. (Answered: Apr 7, 2015 10:48:45 AM PDT)

Question Deadline: Apr 8, 2015 8:00:00 AM PDT

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