Medi-Cal: redeterminations and work or community engagement.

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.

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. 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 an applicable individual to comply with that requirement on a monthly basis, including, among others, a minimum of 80 hours of work, community service, or participation in a work program, 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.

Existing law states 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. Existing law sets forth provisions to conform to the above-described federal provisions, including work or community engagement requirements, exemptions, and notices of noncompliance if applicable.

For purposes of the above-described provisions, the bill would revise the definitions of "applicable individual" and "educational program," as specified. The bill would also revise the definition of "work program" to allow the inclusion of additional programs that comply with federal regulation or directives. The bill would require an applicable individual's total monthly income and average monthly income over the preceding 6 months to be calculated using modified adjusted gross income-based financial methods, as specified, for purposes of demonstrating the individual's work or community engagement.

For beneficiaries who cannot be deemed compliant following ex parte review, the bill would authorize a county to request a Medi-Cal managed care plan to provide any information that will verify that a beneficiary is exempt or meets the requirements. The bill would require the county to request that an applicant or beneficiary confirm information before taking any adverse action on the application or renewal when there is a conflict in reliable data sources that adversely impacts the eligibility of an applicant or beneficiary.

Existing law specifies that if a county is unable to verify that an applicable individual either has met the requirement to demonstrate work or community engagement or was deemed to have demonstrated work or community engagement, the county is required to provide the individual with a notice of noncompliance, as specified, and provide the individual with a period of 30 calendar days to make a satisfactory showing consistent with the work and community engagement requirements.

Under the bill, an applicable individual would be deemed to have received a notice of noncompliance 5 days after the date on the notice. Under the bill, self-attestation by an applicable individual that the individual did not receive a timely notice constitutes good cause for not providing the above-described satisfactory showing. The bill would set forth other procedural steps for the county in reissuing the notice of noncompliance and maintaining or reactivating Medi-Cal eligibility.

This bill would authorize the department to defer implementation of these changes to existing law if these changes would result in a fiscal impact that would require an additional appropriation and that additional appropriation has not been made, as specified.

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.

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.

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.