Medi-Cal: cost sharing and accessibility., the official text

An act to amend Section 15926 of, and to add Section 14134 to, the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

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.
The above-described federal law requires the state, beginning on 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.
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.
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.
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. Existing law authorizes all insurance affordability programs to accept self-attestation for age, date of birth, family size, household income, state residence, pregnancy, work or community engagement activities or exemptions, and any other applicable criteria needed to determine eligibility, to the extent permitted by state and federal law.
This bill would instead require those programs to accept self-attestation, to the extent permitted by state and federal law.
Existing law requires department, the California Health and Human Services Agency, and the California Health Benefit Exchange (Exchange) board to establish a process for receiving and acting on stakeholder suggestions and concerns regarding the Exchange, as specified. Existing law requires this process to 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 and evaluation for Medi-Cal eligibility.
The bill would instead require the establishment of a process for receiving and acting on stakeholder suggestions and concerns regarding the functionality, accuracy, and legally appropriate determination of specified electronic eligibility systems and public internet websites that support Medi-Cal and the Exchange. The bill would also instead require the process to 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 and evaluation for insurance affordability program eligibility.
To the extent these provisions expand duties for counties relating to Medi-Cal and insurance affordability program eligibility, 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.

The people of the State of California do enact as follows:

SECTION 1.
Section 14134 is added to the Welfare and Institutions Code, to read:
14134.
(a) 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:
(1) 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:
(A) Placing the individual’s health or, with respect to a pregnant individual, the health of the pregnant individual or the fetus, in serious jeopardy.
(B) Serious impairment to bodily functions.
(C) Serious dysfunction of any bodily organ or part.
(2) The copayment amounts set forth in paragraph (1) may be collected and retained, or waived by the provider.
(3) 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.
(4) This section does not apply to emergency services, family planning services, or any services received by any of the following:
(A) Services furnished to an individual under 21 years of age.
(B) Any services furnished to an individual who is pregnant.
(C) Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution.
(D) Services furnished to an individual who is receiving hospice care, as defined in Section 1396d(o) of Title 42 of the United States Code.
(E) COVID-19 testing-related services.
(F) Vaccines described in Section 1396d(a)(13)(B) of Title 42 of the United States Code, and the administration of those vaccines.
(G) 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.
(H) Primary care services.
(I) Mental health care and substance use disorder services.
(J) Services provided by a federally qualified health center, certified community behavioral health clinic, or rural health clinic.
(5) A provider of services shall not deny care or services to an individual solely because of nonpayment of copayment under this section.
(6) 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.
(b) 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.

SEC. 2.
Section 15926 of the Welfare and Institutions Code is amended to read:
15926.
(a) The following definitions apply for purposes of this part:
(1) “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.
(2) “Limited-English-proficient” means not speaking English as one’s primary language and having a limited ability to read, speak, write, or understand English.
(3) “Insurance affordability program” means a program that is one of the following:
(A) The Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(B) 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.).
(C) 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.
(D) 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.
(b) 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.
(c) (1) 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.
(2) 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 H.R. 1 (Public Law 119-21).
(3) The application, or any amendments thereto, as required to comply with Public Law 119-21, shall be user-tested for accuracy and readability in all Medi-Cal threshold languages 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.
(4) The application form, or any amendments thereto, shall, to the extent consistent with federal statutes, regulations, and guidance, satisfy all of the following criteria:
(A) The form, or any supplements thereto, shall include simple, user-friendly language and instructions.
(B) The form, or any amendments and supplemental forms thereto, may not ask for information related to a nonapplicant that is not necessary to determine eligibility in the applicant’s particular circumstances.
(C) The form, or any amendments and supplemental forms thereto, may require only information necessary to support the eligibility and enrollment processes for insurance affordability programs.
(D) The form, or any amendments and supplemental forms thereto, may be used for, but shall not be limited to, screening and enrollment into an insurance affordability program.
(E) 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.
(F) 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.
(G) 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.
(H) 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.
(d) 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.
(e) 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.
(f) (1) 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.
(2) 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.
(3) 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.
(4) Before an eligibility determination is made, the individual shall be given the opportunity to provide additional eligibility information and to correct information.
(5) 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.
(6) 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.
(g) 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.
(h) (1) 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.
(2) 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 or noncompliance with the requirements of Section 14005.69, 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.
(3) 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.
(4) 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 provided application information and referred to the county health coverage program in their county of residence.
(i) 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:
(1) 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.
(2) The applicant shall be informed of the penalty for failure to have minimum essential health coverage.
(j) 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.
(k) (1) 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.
(2) 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.
(l) 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 and public internet websites, including CalHEERS, BenefitsCal, and CalSAWS, that support 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 and enhancements of the eligibility systems through regular user-testing and user-centered design sessions. 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 and evaluation for insurance affordability program eligibility.
(m) 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.

SEC. 3.
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.