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<ns0:Id>20250AB__216198AMD</ns0:Id>
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<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-18</ns0:ActionDate>
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<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2026-03-23</ns0:ActionDate>
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<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Bonta</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthors: Assembly Members Boerner and Stefani)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
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<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Bonta</ns0:Name>
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<ns0:Name>Boerner</ns0:Name>
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<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Stefani</ns0:Name>
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<ns0:Title> An act to amend Section 14005.37 of, and to add Section 14005.69 to, the Welfare and Institutions Code, relating to Medi-Cal.</ns0:Title>
<ns0:RelatingClause>Medi-Cal</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Medi-Cal: redeterminations and work or community engagement.</ns0:Subject>
</ns0:GeneralSubject>
<ns0:DigestText>
<html:p>Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is in part governed by, and funded pursuant to, federal Medicaid program provisions.</html:p>
<html:p>Existing federal law, enacted on July 4, 2025, sets forth various changes to Medicaid eligibility with regard to community engagement reporting, redeterminations, cost sharing, and retroactive coverage, among other factors, for certain Medicaid populations, including beneficiaries between 19 and 64 years of age, inclusive, with income up to 138% of the federal poverty level, commonly known as Medicaid expansion adults.</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
For purposes of Medicaid eligibility redeterminations, the above-described federal law requires that a Medicaid expansion adult undergo a redetermination once every 6 months, instead of an annual redetermination, except as specified.
</html:p>
<html:p>Existing state law generally requires a county to perform eligibility redeterminations for Medi-Cal beneficiaries every 12 months and to promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstances, as specified.</html:p>
<html:p>This bill would make changes to those redetermination provisions to conform to the 6-month redetermination requirement under the above-described federal law for Medicaid expansion adults. The bill would make other conforming changes to related provisions.</html:p>
<html:p>Existing state law requires, in the case of a Medi-Cal eligibility redetermination, if the county is unable to determine continued eligibility based on certain information obtained, that the beneficiary be provided with a renewal form that identifies any additional information needed by the county to determine eligibility. Existing law requires that the form include certain details, including that, if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary is required to sign the form in order for it to be considered complete.</html:p>
<html:p>This bill would expand the form delivery mechanisms to include the telephone, online, or commonly available electronic means. The bill would require a county to accept specified methods of signatures.</html:p>
<html:p>By creating new
duties for counties relating to Medi-Cal eligibility redeterminations, the bill would impose a state-mandated local program.</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The above-described federal law generally requires a Medicaid expansion adult, commencing January 1, 2027, or earlier at state option, to demonstrate community engagement as a condition of Medicaid eligibility. Existing law sets forth the mechanisms for complying with that requirement on a monthly basis, including, among others, a minimum of 80 hours of work or community service or a minimum of half-time enrollment in an educational program.
Existing law exempts certain categories of individuals from the requirement, including, among others, a parent or family caregiver of a dependent child 13 years of age or younger or a disabled individual, and a medically frail person.
</html:p>
<html:p>This bill would state the intent of the Legislature that the department implement work or community engagement requirements under the above-described federal law to ensure that all eligible Medi-Cal applicants and beneficiaries obtain and maintain coverage in ways that are least administratively burdensome to those individuals. The bill would set forth provisions to conform to the above-described federal provisions, including work or community engagement requirements, exemptions, and notices of noncompliance if applicable.</html:p>
<html:p>The bill would require the department, before verifying an individual’s compliance, to ensure and confirm that systems are programmed to maintain coverage with minimal data
request to an applicant or beneficiary, as specified. For beneficiaries who cannot be deemed compliant following ex parte review, the bill would require the county to request a Medi-Cal managed care plan to provide any data that will verify that a beneficiary is exempted or meets the requirements before requesting information directly from the beneficiary.</html:p>
<html:p>By creating new duties for counties relating to Medi-Cal eligibility determinations with regard to work or community engagement, the bill would impose a state-mandated local program.</html:p>
<html:p>The bill would require the department to adopt regulations by July 1, 2028. The bill would require the department, beginning July 1, 2027, to provide a semiannual status report on implementation
to the Legislature, until regulations have been adopted.</html:p>
<html:p>Under the bill, these provisions would be implemented only after the Director of Health Care Services determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation. Under the bill, these provisions would remain operative only as long as the above-described federal law is operative.</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The
California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
</html:p>
<html:p>This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.</html:p>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_C1C6C3CD-8A38-4978-A142-916D14891B17">
<ns0:Num>SECTION 1.</ns0:Num>
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Section 14005.37 of the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
is amended to read:
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<ns0:Num>14005.37.</ns0:Num>
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<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Except as provided in paragraph (2) or as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal
beneficiaries, including those individuals who are subject to six-month redeterminations as described in paragraph (2).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
Effective no sooner than January 1, 2027, notwithstanding paragraph (1), with respect to redeterminations of Medi-Cal eligibility scheduled on or after January 1, 2027, a county shall perform redeterminations once every six months for individuals enrolled under Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Subparagraph (A) shall not apply to any individual described in Section 1396a(xx)(9)(A)(ii)(II) of Title 42 of the United States Code, or to any other individual whose
Medicaid eligibility is not specifically required by federal law to be redetermined every six months.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
Except as otherwise
provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiary’s Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The county assesses the beneficiary as being potentially eligible under a program that is exempt
from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The beneficiary requests that the county determine whether the beneficiary is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiary’s Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiary’s file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and
CalFresh case files of the beneficiary or of any of their immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and, wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
In the case of an annual or six-month redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The eligibility determination and the information it is based on.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
That the beneficiary is required to inform the county via the internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiary’s
eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
In the case of an annual or six-month eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual or six-month renewal form, at least 60 days before the beneficiary’s annual or six-month redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional
information needed by the county to determine eligibility. The form shall include all of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The requirement that the beneficiary provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
That the beneficiary may respond to the county via the internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
That if the beneficiary chooses to return the form or renewal information to the county in person, by telephone, online, via mail, or through commonly
available electronic means, the beneficiary shall sign the form or renewal information in order for it to be considered complete. A county shall accept electronic signatures, including telephonically recorded signatures, signatures obtained through an online application, and handwritten signatures transmitted via any other electronic means.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
The telephone number to call in order to obtain more information.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The county shall attempt to contact the beneficiary via the internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form
is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate the beneficiary’s eligibility for Medi-Cal benefits following the provision of timely notice.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is incomplete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
The form
required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that states the information needed to redetermine eligibility. The county shall only request
information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the internet, by telephone, by mail, in person, or through other commonly available electronic means. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions to the form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the
form is mailed pursuant to this subdivision to respond.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for
additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
If, within 90 days of a Medi-Cal beneficiary’s eligibility termination date or a change in eligibility status due to the beneficiary’s failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. The beneficiary shall be entitled to request a Medi-Cal
eligibility determination for any of the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The
forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
</html:p>
<html:p>
(
<html:i>l</html:i>
)
<html:span class="EnSpace"/>
The county shall consider blindness as continuing until the reviewing physician determines that a beneficiary’s vision has improved beyond the applicable definition of blindness contained in the plan.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
The county shall consider disability as continuing until the review team determines that a beneficiary’s disability no longer meets the applicable definition of disability contained in the plan.
</html:p>
<html:p>
(n)
<html:span class="EnSpace"/>
In the case of a redetermination due to a change in circumstances, if a county determines that the
beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month or 6-month eligibility period.
</html:p>
<html:p>
(o)
<html:span class="EnSpace"/>
For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs, and, if the individual is found to be eligible, the county shall, as appropriate, transfer the individual’s electronic account to other insurance affordability programs via a secure electronic interface.
</html:p>
<html:p>
(p)
<html:span class="EnSpace"/>
Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
</html:p>
<html:p>
(q)
<html:span class="EnSpace"/>
The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an internet website identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
</html:p>
<html:p>
(r)
<html:span class="EnSpace"/>
Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
</html:p>
<html:p>
(s)
<html:span class="EnSpace"/>
For purposes of this section, “MAGI-based financial methods” means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and
as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
</html:p>
<html:p>
(t)
<html:span class="EnSpace"/>
When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
</html:p>
<html:p>
(u)
<html:span class="EnSpace"/>
The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
</html:p>
<html:p>
(v)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
</html:p>
<html:p>
(w)
<html:span class="EnSpace"/>
This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal
approvals have been obtained.
</html:p>
<html:p>
(x)
<html:span class="EnSpace"/>
This section shall become operative on January 1, 2014.
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<ns0:Num>SEC. 2.</ns0:Num>
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Section 14005.69 is added to the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
,
<ns0:Positioning>immediately following Section 14005.68</ns0:Positioning>
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<html:p>
(a)
<html:span class="EnSpace"/>
It is the intent of the Legislature that the department implement work or community engagement requirements set forth in Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of federal House Resolution 1 (Public Law 119-21)) to ensure that all eligible Medi-Cal applicants and beneficiaries obtain and maintain coverage in ways that are least administratively burdensome to applicants and beneficiaries.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
For purposes of this section, the following definitions apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Applicable individual” means an individual, other than a specified excluded individual as defined in paragraph (2),
who is either of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
An individual who is eligible to enroll, or is enrolled, in the Medi-Cal program under Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
An individual who has attained 19 years of age and is under 65 years of age, is not pregnant, and is not entitled to, or enrolled for, benefits under federal Medicare Part A (42 U.S.C.
Sec. 1395c et seq.), or eligible for, or enrolled for, benefits under Medicare Part B (42 U.S.C. Sec. 1395j et seq.).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Specified excluded individual” means any of the following individuals:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
An individual who is a foster youth or former foster youth under 26 years of age, as described in Section 1396a(a)(10)(A)(i)(IX) of Title 42 of the United States Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
An Indian or an Urban Indian, as defined in paragraphs (13) and (28) of Section 1603 of Title 25 of the United States Code, respectively.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
A California Indian, as described in Section 1679(a) of Title 25 of the United States Code.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
An individual who has otherwise been determined eligible as an Indian for the Indian Health Service under regulations promulgated by the United States Secretary of Health and Human Services.
</html:p>
<html:p>
(E)
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The parent, guardian, caretaker relative, or family caregiver of a dependent child 13 years of age or younger.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
The parent, guardian, caretaker relative, or family
caregiver of an individual with a chronic or other health condition, disability, or functional limitation.
</html:p>
<html:p>
(G)
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A veteran with a disability rated as total under Section 1155 of Title 38 of the United States Code.
</html:p>
<html:p>
(H)
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An individual who is medically frail or otherwise has special medical needs, as defined by the United States Secretary of Health and Human Services, including, but not limited to, any of the following individuals:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
An individual who is blind or disabled, as defined in Section 1382c of Title 42 of the United States Code.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
An individual with a substance use disorder.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
An
individual with a disabling mental disorder.
</html:p>
<html:p>
(iv)
<html:span class="EnSpace"/>
An individual with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living.
</html:p>
<html:p>
(v)
<html:span class="EnSpace"/>
An individual with a serious or complex medical condition.
</html:p>
<html:p>
(I)
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An individual in compliance with the work requirements under the federal Temporary Assistance for Needy Families (TANF).
</html:p>
<html:p>
(J)
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A member of a household that receives supplemental nutrition assistance program benefits under the federal Food and Nutrition Act of 2008 (Public Law 88-525) and is not exempt from a work requirement under that act.
</html:p>
<html:p>
(K)
<html:span class="EnSpace"/>
An individual participating in a drug addiction or alcoholic treatment and rehabilitation program, as defined in Section 2012(h) of Title 7 of the United States Code.
</html:p>
<html:p>
(L)
<html:span class="EnSpace"/>
An inmate of a public institution.
</html:p>
<html:p>
(M)
<html:span class="EnSpace"/>
An individual who is pregnant or entitled to postpartum medical assistance under Section 1396a(e)(5) or (16) of Title 42 of the United States Code.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
“Educational program” includes both of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
An institution of higher education, as defined in Section 1001 of Title 20 of the United States Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
A program of career and technical education, as defined in Section
2302 of Title 20 of the United States Code.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
“Work program” has the meaning as set forth in Section 2015(o)(1) of Title 7 of the United States Code, which includes, among other programs, certain employment and training programs described in paragraph (4) of subdivision (d) of that section, subject to the exclusions described in paragraph (1) of subdivision (o) of that section.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
Before verifying an individual’s compliance with work or community engagement requirements, the department shall ensure and confirm that systems are programmed to maintain coverage with minimal data request to an applicant or beneficiary by doing both of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Limiting compliance to applicants or beneficiaries who are federally
required under Section 1396a(xx) of Title 42 of the United States Code to meet work or community engagement requirements.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Measuring compliance through interfaces with data sources that include, but are not limited to, wage data, gig economy, Medi-Cal eligibility aid codes, Medi-Cal claims and encounter data, and data from the State Department of Social Services.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
No sooner than January 1, 2027, pursuant to the requirements set forth in Section 1396a(xx) of Title 42 of the United States Code, as a condition of Medi-Cal eligibility and following the department’s confirmation that systems are programmed to maintain coverage with minimal data request to an applicable individual, an applicable individual shall demonstrate work or community engagement.
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
An applicable individual who applies for the Medi-Cal program shall demonstrate work or community engagement for one month immediately preceding the month during which the individual applies for the Medi-Cal program.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
An applicable individual enrolled and receiving Medi-Cal services shall demonstrate work or community engagement for any one month during the period between the individual’s most recent determination or redetermination, as applicable, of eligibility and their next regularly scheduled redetermination of eligibility as described in Section 14005.37.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
Subject to this subdivision and subdivision (f), an applicable individual demonstrates work or community engagement for a month if they meet one or
more of the following conditions with respect to that month, as determined in accordance with criteria established by federal regulation:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The individual works no less than 80 hours.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The individual completes no less than 80 hours of community service.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The individual participates in a work program for no less than 80 hours.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The individual is enrolled in an educational program at least half-time.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The individual engages in any combination of the activities described in paragraphs (1) to (4), inclusive, for a total of no less than 80 hours.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
The individual has a total monthly income, including, but not limited to, earned income, unemployment benefits, state disability insurance, retirement income, or dividends, that is no less than the applicable minimum wage requirement under Section 206 of Title 29 of the United States Code, multiplied by 80 hours.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
The individual had an average monthly income, including, but not limited to, earned income, unemployment benefits, state disability insurance, retirement income, or dividends, over the preceding six months that is no less than the applicable minimum wage requirement under Section 206 of Title 29 of the United
States Code, multiplied by 80 hours, and is a seasonal worker, as described in Section 45R(d)(5)(B) of the federal Internal Revenue Code of 1986.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
An applicable individual is excluded from work or community engagement requirements under subdivision (d) for a month if, for part or all of the month, the individual either is a specified excluded individual, as defined under paragraph (2) of subdivision (b), or is any of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
An individual under 19 years of age.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
An individual entitled to, or enrolled for, benefits under federal Medicare Part A (42 U.S.C.
Sec. 1395c et seq.), or enrolled for benefits under federal Medicare Part B (42 U.S.C. Sec. 1395j et seq.).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
An individual described in any of subclauses (I) through (VII) of Section 1396a(a)(10)(A)(i) of Title 42 of the United States Code.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
An inmate of a public institution at any point during the three-month period ending on the first day of that month.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
An individual excluded based on any other federally required or approved exemptions outlined in the state plan or waivers.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Any other individual not specifically required by federal law to comply with work or community engagement requirements.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
An applicable individual shall be deemed to have demonstrated work or community engagement under subdivision (d) for that month if they experience a short-term hardship.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
For purposes of this section, and in accordance with applicable federal law, an applicable individual experiences a short-term hardship event during a month if, for part or all of that month, any of the following is met:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The individual receives inpatient hospital services, nursing facility services, services in an intermediate care facility for individuals with
intellectual disabilities, inpatient psychiatric hospital services, or other services of similar acuity, including outpatient care relating to other services specified in this paragraph, as determined by the United States Secretary of Health and Human Services, and the individual requests a short-term hardship exemption.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The individual resides in a county in which an emergency or disaster was declared by the United States President pursuant to the federal National Emergencies Act (50 U.S.C. Sec. 1601 et seq.) or the federal Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. Sec. 5121 et seq.).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The individual resides in a county with an unemployment rate that is at or above the lesser of 8 percent or 1.5 times the national unemployment rate,
subject to a request from the department to the United States Secretary of Health and Human Services.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The individual or their dependent must travel outside of their community for an extended period of time to receive medical services necessary to treat a serious or complex medical condition, as described in Section 1396a(xx)(9)(A)(ii)(V)(ee) of Title 42 of the United States Code, that are not available within their community of residence, and the individual requests a short-term hardship exemption.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
For beneficiaries who cannot be deemed compliant following
ex parte review, as required by Section 1396a(xx)(5) of Title 42 of the United States Code, the county shall request a Medi-Cal managed care plan to provide any data that will verify that a beneficiary is exempted or meets work or community engagement requirements before requesting information directly from the beneficiary.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
When there is a conflict in reliable data sources that adversely impacts an applicant’s or beneficiary’s eligibility, the county shall use data that are most beneficial to the applicant or beneficiary or to maintain eligibility following verification from an applicant or beneficiary.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
For purposes of verifying that an applicable individual has met the requirement to demonstrate work or community engagement under
subdivision (e), or determining that the individual is excluded from, or deemed to have demonstrated, work or community engagement under subdivision (f) or (g), or determining that the individual is a specified excluded individual under paragraph (2) of subdivision (b), the department shall establish processes and use available and reliable information without requiring, where possible and only when sufficient verification has been submitted, the applicable individual to submit additional information.
</html:p>
<html:p>
(l)
<html:span class="EnSpace"/>
If a county is unable to verify that an applicable individual either has met the requirement to demonstrate work or community engagement under subdivision (e) or was deemed to have demonstrated work or community engagement under subdivision (f) or (g), the county shall do all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Provide the applicable individual with the notice of noncompliance described in subdivision (n).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Provide the applicable individual with a period of 30 calendar days, beginning on the date on which the notice of noncompliance is received by the individual, to do any of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Make a satisfactory showing of compliance with the requirement for work or community engagement under subdivision (e).
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Make a satisfactory showing that the applicable individual was deemed to have demonstrated work or community engagement under subdivision (f) or (g).
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Make a satisfactory showing that the work or community engagement requirement
does not apply to the individual on the basis that the individual does not meet the definition of applicable individual under paragraph (1) of subdivision (b).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Continue to provide the applicable individual with Medi-Cal services during the 30-calendar-day period if the applicable individual is enrolled in the Medi-Cal program.
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
For an applicable individual newly applying for the Medi-Cal program, the county shall approve applicants pending verification of work or community engagement and maintain active Medi-Cal eligibility until at least the last day of the 30-calendar-day period.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
For an applicable individual renewing their Medi-Cal enrollment during a six-month redetermination period, the county shall maintain active eligibility until at least the last day of the month of the 30-calendar-day period.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
For purposes of this subdivision, an applicable individual is deemed to have received the notice of noncompliance 10 business days after the county provides the letter to the United States Postal Service, except when the applicable individual attests to not receiving the notice or has good cause for not meeting the 30-calendar-day period.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
When an applicable individual attests to not receiving the notice of noncompliance or has good cause, the county shall maintain or reactivate Medi-Cal eligibility, without a gap in coverage, until the applicable time period in subparagraph (A) or (B) expires.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Deny the applicable individual’s application for the Medi-Cal program, or disenroll the individual from the Medi-Cal program, if no satisfactory showing is made pursuant to paragraph (2) and the applicable individual is not a specified excluded individual as defined in paragraph (2) of subdivision (b), no later than the end of the month following the month in which the 30-calendar-day period ends.
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Before denying the applicable individual’s application
or disenrolling the individual, the county shall first do both of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Determine whether there is any other basis for eligibility for the Medi-Cal program or for another insurance affordability program for the individual.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Provide written notice and grant the individual an opportunity for a fair hearing.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
As specified by the department, and pursuant to federal requirements, the county shall notify applicable individuals enrolled in the Medi-Cal program of the requirement to demonstrate work or community engagement pursuant to this section.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The notice required under paragraph (1) shall be delivered by
regular mail or, if elected by the individual, in an electronic format, and shall be delivered in one or more additional forms, which may include telephone, text message, an internet website, other commonly available electronic means, and such other forms as the United States Secretary of Health and Human Services determines appropriate.
</html:p>
<html:p>
(n)
<html:span class="EnSpace"/>
The notice of noncompliance provided to an applicable individual shall be on a form prescribed by the department and shall include the name and telephone number of the county department worker, county department call center, or other appropriate county department contact that is available to assist applicants and beneficiaries with questions about their notice, and the date the form was completed. A copy of the notice shall be placed in the case file. The notice shall include all of the following information:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
A statement explaining that the applicable individual has been determined to be subject to work or community engagement requirements, including the specific factual basis for that determination and the applicable law or regulation.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A statement explaining that the applicable individual has been determined to be noncompliant with work or community engagement requirements, and a description of how the individual may make a satisfactory showing as described in paragraph (2) of subdivision (l).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
An outline of how the individual may reapply for the Medi-Cal program if the individual’s application is denied or the individual is disenrolled.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The
applicable individual’s right to request a state hearing, including the procedures for requesting a state hearing and the time limits within which a state hearing must be requested.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The circumstances under which aid will be continued if a state hearing is requested.
</html:p>
<html:p>
(o)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, until regulations are adopted.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The department shall adopt regulations by July 1, 2028, for purposes of this section, in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Notwithstanding Section 10231.5 of the Government Code, beginning July 1, 2027, the department shall provide a semiannual status report on implementation of this section to the Legislature, in accordance with Section 9795 of the Government Code, until regulations have been adopted.
</html:p>
<html:p>
(p)
<html:span class="EnSpace"/>
This section shall remain operative only as long as Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of federal House Resolution 1 (Public Law 119-21)) is operative.
</html:p>
<html:p>
(q)
<html:span class="EnSpace"/>
This section shall be implemented only after the director determines, and communicates in writing to the Department of Finance,
that systems have been programmed for implementation of this section.
</html:p>
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</ns0:BillSection>
<ns0:BillSection id="id_C3D12210-9013-4774-B3C0-0246F8B7FDE1">
<ns0:Num>SEC. 3.</ns0:Num>
<ns0:Content>
<html:p>If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.</html:p>
</ns0:Content>
</ns0:BillSection>
</ns0:Bill>
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