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<ns0:Id>20250AB__220899INT</ns0:Id>
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<ns0:Action>
<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-19</ns0:ActionDate>
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<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:MeasureType>AB</ns0:MeasureType>
<ns0:MeasureNum>2208</ns0:MeasureNum>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Stefani</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthors: Assembly Members Boerner and Bonta)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Stefani</ns0:Name>
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<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Boerner</ns0:Name>
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<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Bonta</ns0:Name>
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<ns0:Title> An act to amend Sections 14005.37, 14016.2, 14019, and 15926 of, and to add Section 14134 to, the Welfare and Institutions Code, relating to Medi-Cal.</ns0:Title>
<ns0:RelatingClause>Medi-Cal</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Medi-Cal: cost sharing, retroactivity, and accessibility.</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> The above-described federal law requires the state, beginning October 1, 2028, to impose
deductions, cost sharing, or similar charges determined appropriate by the state, in an amount greater than $0, with respect to certain care, items, or services furnished to Medicaid expansion adults, with income exceeding 100% and up to 138% of the federal poverty level, as determined by the state. The federal law excludes certain services from these provisions and prohibits the charge from exceeding $35.</html:p>
<html:p>This bill would, no sooner than October 1, 2028, set a copayment of $0.01 for nonemergency services for the above-described population, as specified. The bill would authorize the provider to collect, retain, or waive the copayment amount. The bill would not apply the copayment requirements to emergency services, family planning services, or any services under certain categories. The bill would prohibit a service provider from denying care or services to an individual solely because of nonpayment of copayment.</html:p>
<html:p> The bill
would create an exemption from a copayment requirement for any visit, service, device, or item for which the Medi-Cal program’s payment is $10 or less. The bill would prohibit the total aggregate amount of deductions, cost sharing, or similar charges imposed for all individuals in a family from exceeding 5% of the family income.</html:p>
<html:p>The above-described federal law reduces the period of retroactive coverage prior to the date of Medicaid application from 3 months to one month for Medicaid expansion adults and to 2 months for other Medicaid beneficiaries.</html:p>
<html:p>Under state law, a Medi-Cal card is authorization for payment for health care services rendered, to the extent required by federal law, during any of the 3 months immediately before the month of application and for which the person would have otherwise been eligible.</html:p>
<html:p>Under this bill, upon request by an individual who is determined to be
eligible for the Medi-Cal program, assistance would be made available for care and services, whether federally funded or state-funded, and furnished during any of the 3 months immediately before the month of application, if the individual was, or upon application would have been, eligible for medical assistance. The bill would make conforming changes to related provisions, with specification that the 3 months of retroactive eligibility would be federally funded or state funded, with federal reimbursement sought to the maximum extent federally allowable.</html:p>
<html:p>Existing law requires the department to develop a single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs, including Medi-Cal, for use by all entities authorized to make an eligibility determination for those programs.</html:p>
<html:p>This bill would require that the application be user-tested for accuracy and readability and be
operational by the date as required by the federal Secretary of Health and Human Services, including before the effective date of any applicable changes required pursuant to the above-described federal law. The bill would authorize use of the application form, to the extent possible, to determine compliance with work or community engagement requirements set forth in the federal law, including any exemptions to those requirements, without seeking additional information.</html:p>
<html:p>Existing law authorizes all insurance affordability programs to accept self-attestation for age, date of birth, family size, household income, state residence, pregnancy, and any other applicable criteria needed to determine eligibility, to the extent permitted by state and federal law.</html:p>
<html:p>This bill would instead require those programs to accept self-attestation, and would incorporate work or community engagement activities or exemptions into that
self-attestation provision, to the extent permitted by state and federal law. The bill would incorporate work or community engagement into other related provisions, and would make other changes to eligibility systems.</html:p>
<html:p>By creating new duties for counties relating to Medi-Cal eligibility and coverage determinations, the bill would impose a state-mandated local program.</html:p>
<html:p>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:VoteRequired>MAJORITY</ns0:VoteRequired>
<ns0:Appropriation>NO</ns0:Appropriation>
<ns0:FiscalCommittee>YES</ns0:FiscalCommittee>
<ns0:LocalProgram>YES</ns0:LocalProgram>
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<ns0:Bill id="bill">
<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_7FBF1A04-89F2-42A4-A7D6-42E85936A923">
<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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<html:p>
(a)
<html:span class="EnSpace"/>
Except 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.
</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 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 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 renewal form, at least 60 days before the beneficiary’s annual 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 to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
</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"/>
(1)
<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, whether federally funded or state funded.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Federal reimbursement for costs associated with implementation of this subdivision shall be sought to the maximum extent federally allowable.
</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 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.
</html:p>
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<ns0:BillSection id="id_8C3A450F-F133-4F74-8DC3-3DCD15291857">
<ns0:Num>SEC. 2.</ns0:Num>
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Section 14016.2 of the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
is amended to read:
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<ns0:Num>14016.2.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
If a person who is incapable of acting on their own behalf and who would otherwise be eligible is discontinued from Medi-Cal eligibility because the guardian or authorized representative of the person fails or refuses to provide information needed to determine eligibility, then anyone with knowledge of the person’s need for Medi-Cal coverage may apply for retroactive eligibility for any of the three preceding months on
behalf of the
person, whether federally funded or state funded. If the necessary information becomes available within three months of the application, the county department shall act on the application to determine the person’s eligibility for the retroactive period.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
Federal reimbursement
for costs associated with implementation of this section shall be sought to the maximum extent federally allowable.
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<ns0:BillSection id="id_D041EB36-1C4A-4019-9602-C5F496D0FF6E">
<ns0:Num>SEC. 3.</ns0:Num>
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Section 14019 of the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
is amended to read:
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<ns0:Fragment>
<ns0:LawSection id="id_A5172687-EE9C-4DA4-A0D1-892E58920C54">
<ns0:Num>14019.</ns0:Num>
<ns0:LawSectionVersion id="id_41A86A24-53B6-4270-817E-E793D4F3FFB7">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
Notwithstanding the provisions of Section 14018, except as provided in Sections 14019.1 and 14019.6, a Medi-Cal card shall be authorization for payment for health care services rendered, under conditions prescribed by the director and as described in subdivision (b), during any of the three months immediately prior to the month in which application was made, and for which
the person would have otherwise been eligible.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
Upon request by an individual who is determined to be eligible for medical assistance under this chapter, assistance shall be made available for care and services included under the state plan, whether federally funded or state funded, and furnished during any of the three months immediately prior to the month of the application, if the individual was, or upon application would have been, eligible for medical assistance at the time care and services were furnished.
</html:p>
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</ns0:BillSection>
<ns0:BillSection id="id_F906E5CF-C21A-43C6-B136-53EBC9260AC1">
<ns0:Num>SEC. 4.</ns0:Num>
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Section 14134 is added to the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
, to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_4B7FE74C-E4AB-480F-AD96-ACDF0C2CFFD7">
<ns0:Num>14134.</ns0:Num>
<ns0:LawSectionVersion id="id_8D3342E7-7ADA-4524-A869-CDE6C1C0818B">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
Except for any visit, service, device, or item for which the Medi-Cal program’s payment is ten dollars ($10) or less, in which case no copayment shall be required, “newly eligible beneficiaries,” as defined in subdivision (s) of Section 17612.2, with income exceeding 100 percent of, and up to 138 percent of, the federal poverty level with the federal 5-percent disregard in consideration, shall be required to make copayments not to exceed the maximum permitted under federal regulations or federal waivers, as follows:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Copayment of one cent ($0.01) shall be made for nonemergency services received in an emergency department or emergency room when the services do not result in the treatment of an emergency medical condition or inpatient
admission. For purposes of this section, “nonemergency services” means services not required to, as appropriate, medically screen, examine, evaluate, or stabilize an emergency medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, so that the absence of immediate medical attention could reasonably be expected to result in any of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Placing the individual’s health or, with respect to a pregnant individual, the health of the pregnant individual or pregnant individual’s unborn child, in serious jeopardy.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Serious impairment to bodily functions.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Serious dysfunction of any bodily organ or part.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The copayment amounts set forth in paragraph (1) may be collected and retained, or waived
by the provider.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The department shall not reduce the reimbursement otherwise due to providers as a result of the copayment. The copayment amounts shall be in addition to any reimbursement otherwise due to the provider for services rendered under the Medi-Cal program.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
This section does not apply to emergency services, family planning services, or any services received by any of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Services furnished to an individual under 21 years of age.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Any services furnished to an individual who is pregnant.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Services furnished to an individual who is receiving hospice care, as defined in Section 1396d(o) of Title 42 of the United States Code.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
COVID-19 testing-related services.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Vaccines described in Section 1396d(a)(13)(B) of Title 42 of the United States Code, and the administration of those vaccines.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Items or services furnished to Indians through the federal Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or through referral under contract health services.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Primary care services.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Mental health care and substance use disorder services.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
Services provided by a federally qualified health center, certified community behavioral health clinic, or rural health clinic.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
A provider of services shall not deny care or services to an individual solely because of nonpayment of copayment under this section.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
The total aggregate amount of deductions, cost sharing, or similar charges imposed for all individuals in a family shall not exceed 5 percent of the family income of the family involved, as applied on a monthly basis.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available, and no sooner than October 1, 2028.
</html:p>
</ns0:Content>
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</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_796C0185-8B43-4C20-9317-240F5A1602B9">
<ns0:Num>SEC. 5.</ns0:Num>
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Section 15926 of the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
is amended to read:
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<ns0:Fragment>
<ns0:LawSection id="id_6DD8E150-0D5F-4DD2-9D94-45C18B44EF4C">
<ns0:Num>15926.</ns0:Num>
<ns0:LawSectionVersion id="id_586BE2FB-4267-4114-8C56-4F084E0E4787">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
The following definitions apply for purposes of this part:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Accessible” means in compliance with Section 11135 of the Government Code, Section 1557 of the PPACA, and regulations or guidance adopted pursuant to these statutes.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Limited-English-proficient” means not speaking English as one’s primary language and having a limited ability to read, speak, write, or understand English.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
“Insurance affordability program” means a program that is one of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.).
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The state’s children’s health insurance program (CHIP) under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
A program that makes available to qualified individuals coverage in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
A program that makes available coverage in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code with cost-sharing reductions established under Section 1402 of PPACA and any subsequent amendments to that act.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
An individual shall have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic
means, including a mobile-friendly internet website.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs shall be developed by the department, in consultation with the board governing the Exchange, as part of the stakeholder process described in subdivision (b) of Section 15925. The application shall be used by all entities authorized to make an eligibility determination for any of the insurance affordability programs and by their agents.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The department may develop and require the use of supplemental forms to collect additional information needed to determine eligibility on a basis other than the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, 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, as provided under Section 435.907(c) of Title 42 of the Code of Federal Regulations, and as amended by federal House Resolution 1 (Public Law 119-21).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The application, or any
amendments thereto, as required to comply with Public Law 119-21, shall be user-tested for accuracy and readability and shall be operational by the date as required by the federal Secretary of Health and Human Services, including prior to the effective date of any applicable changes required pursuant to Public Law 119-21.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The application form, or any amendments thereto, shall, to the extent not inconsistent with federal statutes, regulations, and guidance, satisfy all of the following criteria:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The
form, or any supplements thereto, shall include simple, user-friendly language and instructions.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The form, or any supplements thereto, may not ask for information related to a nonapplicant that is not necessary to determine eligibility in the applicant’s particular circumstances.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
The form, or any supplements thereto, may require only information necessary to support the eligibility and enrollment processes for insurance affordability programs.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
The
form, or any supplements thereto, may be used for, but shall not be limited to, screening and enrollment into an insurance affordability program.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
The form may ask, or be used otherwise to identify, if the mother of an infant applicant under one year of age had coverage through an insurance affordability program for the infant’s birth, for the purpose of automatically enrolling the infant into the applicable program without the family having to complete the application process for the infant.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
The form may include questions that are voluntary for applicants to answer regarding demographic data categories, including race, ethnicity,
primary language, disability status, and other categories recognized by the federal Secretary of Health and Human Services under Section 4302 of the PPACA.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Notwithstanding subparagraphs (B) and (C), on or before January 1, 2027, the form shall include an optional question for an applicant to identify whether they are experiencing homelessness.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
The form may be used, to the extent possible, to determine compliance with work or community engagement requirements set forth in Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of Public Law 119-21), as described in Section 14005.69, including any exemptions to those requirements, without seeking additional information.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
Nothing in this section shall preclude the use of a provider-based application form or enrollment procedures for insurance affordability programs or other health programs that differs from the application form described in subdivision (c), and related enrollment procedures. Nothing in this section shall preclude the use of a joint application, developed by the department and the State Department of Social Services, that allows for an application to be made for multiple programs, including, but not limited to,
CalWORKs, CalFresh, and insurance affordability programs.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
The entity making the eligibility determination shall grant eligibility immediately whenever possible and with the consent of the applicant in accordance with the state and federal rules governing insurance affordability programs.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
If the eligibility, enrollment, and retention system has the ability to prepopulate an application form for insurance affordability programs with personal information from available electronic databases, an applicant shall be given the option, with their informed consent, to have the application form prepopulated. Before a prepopulated application is submitted to the entity authorized to make eligibility determinations, the individual shall be given the opportunity to provide additional eligibility information and to correct any information retrieved from a
database.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
All insurance affordability programs shall accept self-attestation, instead of requiring an individual to produce a document, for age, date of birth, family size, household income, state residence, pregnancy, work or community engagement activities or exemptions to those requirements, and any other applicable criteria needed to determine the eligibility of an applicant or recipient, to the extent permitted by state and federal law.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
An applicant or recipient shall have their information electronically verified in the manner required by the
PPACA, Public Law 119-21, and implementing federal regulations and guidance and state law.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Before an eligibility determination is made, the individual shall be given the opportunity to provide additional eligibility information and to correct information.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The eligibility of an applicant shall not be delayed beyond the timeliness standards as provided in Section 435.912 of Title 42 of the Code of Federal Regulations or denied for any insurance affordability program unless the applicant is given a reasonable opportunity, of at least the kind provided for under the Medi-Cal program pursuant to Section 14007.5 and paragraph (7) of subdivision (e) of Section 14011.2, to resolve discrepancies concerning any information provided by a verifying
entity, including the opportunity to provide information to demonstrate compliance with work or community engagement requirements pursuant to Section 14005.69.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
To the extent federal financial participation is available, an applicant shall be provided benefits in accordance with the rules of the insurance affordability program, as implemented in federal regulations and guidance, for which the applicant otherwise qualifies until a determination is made that the applicant is not eligible and all applicable notices have been provided. Nothing in this section shall be interpreted to grant presumptive eligibility if it is not otherwise required by state law, and, if so required, then only to the extent permitted by federal law.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
The eligibility, enrollment, and retention system shall offer an applicant and recipient assistance with their
application or renewal for an insurance affordability program in person, over the telephone, by mail, online, or through other commonly available electronic means and in a manner that is accessible to individuals with disabilities and those who are limited English proficient.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
During the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for an insurance affordability program shall ensure that an eligible applicant and recipient of insurance affordability programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary. The individual shall be informed about how to obtain information
about the status of their application, renewal, or transfer to another program at any time, and the information shall be promptly provided when requested.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The application or case of an individual screened as not eligible for Medi-Cal on the basis of Modified Adjusted Gross Income (MAGI) household income but who may be eligible on the basis of being 65 years of age or older, or on the basis of blindness or disability, shall be forwarded to the Medi-Cal program for an eligibility determination. During the period this application or case is processed for a non-MAGI Medi-Cal eligibility determination, if the applicant or recipient is otherwise eligible for an insurance affordability program, the applicant or recipient shall be determined eligible for that program.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Renewal procedures shall include all available methods for reporting renewal information, including, but not
limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means, including smart phones or other smart devices.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
An applicant who is not eligible for an insurance affordability program for a reason other than income eligibility, including work or community engagement requirements,
or for any reason in the case of applicants and recipients residing in a county that offers a health coverage program for individuals with income above the maximum allowed for the Exchange premium tax credits, shall be referred to the county health coverage program in their county of residence.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Notwithstanding subdivisions (e), (f), and (j), before an online applicant who appears to be eligible for the Exchange with a premium tax credit or reduction in cost sharing, or both, may be enrolled in the Exchange, both of the following shall occur:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The applicant shall be informed of the overpayment penalties under the federal Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 (Public Law 112-9), if the individual’s annual family income increases by a specified amount or more, calculated on the basis of the individual’s
current family size and current income, and that penalties are avoided by prompt reporting of income increases throughout the year.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The applicant shall be informed of the penalty for failure to have minimum essential health coverage.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
The department shall, in coordination with the Exchange board, streamline and coordinate all eligibility rules and requirements among insurance affordability programs using the least restrictive rules and requirements permitted by federal and state law. This process shall include the consideration of methodologies for determining income levels, assets, rules for household size, citizenship and immigration status, work or community engagement and related exemptions, and self-attestation and verification requirements.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Forms and notices developed pursuant to this section shall be accessible and standardized, as appropriate, and shall comply with federal and state laws, regulations, and guidance prohibiting discrimination.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Forms and notices developed pursuant to this section shall be developed using plain language and shall be provided in a manner that affords meaningful access to limited-English-proficient individuals, in accordance with applicable state and federal law, and at a minimum, provided in the same threshold languages as required for Medi-Cal managed care plans.
</html:p>
<html:p>
(l)
<html:span class="EnSpace"/>
The department, the California Health and Human Services Agency, and the Exchange board shall establish a process for receiving and acting on stakeholder suggestions
and concerns regarding the functionality, accuracy, and legally appropriate determination of the electronic eligibility systems, including CalHEERS, BenefitsCal, and CalSAWS, supporting Medi-Cal and the Exchange, including the activities of all entities providing eligibility screening to ensure the correct eligibility rules and requirements are being used. This process shall include consumers and their advocates, be conducted no less than quarterly, and include the recording, review, and analysis of potential defects or enhancements of the eligibility systems through regular user-testing. The process shall also include regular updates on the work to analyze, prioritize, and implement corrections to confirmed defects and proposed
enhancements to the eligibility systems, and to monitor screening.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
In designing and implementing the eligibility, enrollment, and retention system, the department and the Exchange board shall ensure that all privacy and confidentiality rights under the PPACA, Public Law 119-21, and other federal and state laws are incorporated and followed, including responses to security breaches.
</html:p>
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</ns0:LawSection>
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</ns0:BillSection>
<ns0:BillSection id="id_3AF5DBC8-CD41-4953-A5AE-A6DDB15F9959">
<ns0:Num>SEC. 6.</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>
</ns0:MeasureDoc>