Medi‑Cal eligibility redetermination and community engagement requirements
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Amends state law to change Medi‑Cal redetermination frequency for some beneficiaries, set procedures for redeterminations and notices, and add a community engagement requirement for certain adult Medi‑Cal enrollees; affects counties and beneficiaries.
Redetermination frequency is changed so counties must perform eligibility redeterminations once every 6 months (semiannual) for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII) effective no sooner than January 1, 2027.
Introduces a new statutory community engagement requirement as a condition of eligibility for 'applicable individuals' (certain adults) beginning no sooner than January 1, 2027.
Modifies post‑termination reenrollment windows and redetermination handling: narrowed months of retroactive eligibility available depending on cohort beginning January 1, 2027, and repeal of a prior paragraph effective Dec 31, 2026.
Specifies allowed contact and submission methods (internet, phone, mail, in person, electronic means) and acceptance of electronic/telephonic signatures under penalty of perjury.
Eligibility rules for persons who are not U.S. citizens or nationals are changed: phased limitations on full‑scope benefits, expanded emergency/pregnancy‑only coverage, and age‑based carveouts with implementation gating based on system readiness.
Monthly premiums of $30 are imposed for many noncitizen cohorts as a condition of full‑scope Medi‑Cal eligibility beginning no sooner than specified dates, with exemptions for under 19, over 59, and pregnant individuals and penalties after nonpayment.
Eligibility and Coverage Criteria
Community engagement as condition of eligibility for applicable individuals (no sooner than Jan 1, 2027)
Covered when ALL of the following are met for 'applicable individuals' (condition of eligibility no sooner than January 1, 2027):
ONE of the following must be met for the demonstration month
- Work for no less than 80 hours in the month.
- Complete no less than 80 hours of community service in the month.
- Participate in a work program for no less than 80 hours in the month.
- Be enrolled in an educational program at least half-time (as referenced in Higher Education Act and Carl D. Perkins Act).
- Engage in any combination of the activities above totaling no less than 80 hours in the month.
- Have total monthly income equal to or exceeding the applicable federal minimum wage multiplied by 80 hours (or averaged monthly income over preceding 6 months for qualifying seasonal workers as described).
Deemed compliant / exempt categories (automatically demonstrate engagement)
- Under age 19 for part or all of the month.
- Entitled to or enrolled for benefits under Medicare Part A or Part B for part or all of the month.
- Described among specified subclauses under 42 U.S.C. §1396a(a)(10)(A)(i) for part or all of the month.
- An inmate of a public institution at any point during the 3‑month period ending on the first day of that month (counts as deemed compliant for that month).
- Any other federally required and approved exemptions as provided in the state plan or waivers.
Short‑term hardship exception (county discretion via department procedures)
- Approved short‑term hardship events include, for part or all of the month: inpatient hospital services, nursing facility services, ICF‑IID inpatient services, inpatient psychiatric hospital services, or other comparable high‑acuity services.
- County or presidentially declared disaster county residency during the month.
- Residence in a county with unemployment at or above the lesser of 8% or 1.5× the national unemployment rate (short‑term hardship).
Redetermination and renewals procedures applicable to Medi‑Cal beneficiaries
Redetermination and renewal procedures (applies to all Medi‑Cal beneficiaries; semiannual redetermination applies to specified population effective no sooner than Jan 1, 2027):
Coverage scope for persons who are not U.S. citizens or nationals (tiered by immigration status, age, and documentation; phased implementation)
Coverage scope and eligibility rules for persons who are not U.S. citizens or nationals (phased implementation with system‑readiness gating):
Age, pregnancy, and nonminor dependent carveouts/exemptions
- Individuals under 19 years of age are generally exempt from premium and some service limitations; they remain eligible for full scope benefits as specified.
- Individuals who are pregnant are exempt from the monthly premium requirement and certain service limitations.
- Nonminor dependents and individuals who would be eligible but for their immigration status under Section 14005.28 remain eligible for full‑scope Medi‑Cal benefits until their 26th birthday and are exempt from monthly premium and service‑limitation rules.
Medi‑Cal coverage conditions and limitations introduced (premiums, exemptions, service limitations, dental limits)
Medi‑Cal coverage conditions and limitations (new requirements, exemptions, and service limits):
Billing, Codes, and Key Numeric Parameters
| N/A | This document amends state law; no clinical/coding lists provided in this part. |
| No explicit procedure or billing codes are specified in this part of the document. |
| No codes listed |
County and Provider Operational Requirements
Semiannual redeterminations for specified cohort
Effective no sooner than January 1, 2027, counties must perform eligibility redeterminations once every 6 months (semiannual) for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII); the standard 12‑month redetermination interval continues to apply to other beneficiaries.
Verify community engagement; issue notice and 30‑day cure period
Counties must verify that applicable individuals demonstrate required monthly community engagement (or are exempt/deemed compliant) and follow a defined noncompliance process: if unable to verify engagement, the county must provide a notice of noncompliance and a 30‑calendar‑day period to make a satisfactory showing; Medi‑Cal services continue during that 30‑day period.
- Applicable individuals must demonstrate community engagement for the month immediately preceding an application and for one month between determinations for enrolled individuals (Section 14005.69).
- Counties must use available, reliable information and processes to verify engagement and avoid requiring additional information when sufficient verification exists.
- Notice must describe how to make a satisfactory showing and outline reapplication and hearing rights.
Transmit enrollee address updates to counties
Managed care entities and prepaid plans must promptly transmit to counties any enrollee address information that is provided to or verified by the entity or plan directly with the individual, beginning January 1, 2027.
- Address reporting requirement applies to managed care entities, prepaid inpatient health plans, and prepaid ambulatory health plans as defined in federal law.
- This requirement is contingent on the director's written determination to the Department of Finance that systems are programmed for implementation.
Notice, 30‑day cure period, and continuation of benefits
If a county cannot verify community engagement, it must provide a notice of noncompliance that explains how to make a satisfactory showing and allow a 30‑calendar‑day cure period; Medi‑Cal benefits must continue during that 30‑day period and disenrollment or denial actions may not occur until after the cure period and applicable due process.
- Notice must include how to make a satisfactory showing and information about reapplying or requesting a fair hearing.
- If no satisfactory showing is made, termination or disenrollment may occur no later than the end of the month following the 30‑day period (per statute).
Modified retroactive authorization look‑back windows
The retroactive payment authorization window for Medi‑Cal cards is narrowed for applications on or after the first quarter beginning after December 31, 2026: applicants under 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) receive authorization for services in the single month immediately prior to application; other applicants receive authorization for services in the two months immediately prior to application; earlier general three‑month authorization remains where applicable.
- These timing changes are subject to conditions and to director certification that systems are programmed prior to implementation.
Department authority to issue implementation guidance and gating
The Department may implement, interpret, or make specific these statutory sections by plan or county letters, information notices, plan or provider bulletins, or similar instructions without undertaking Chapter 3.5 rulemaking; many provisions are also conditioned on the director's written communication to the Department of Finance that systems have been programmed.
- Providers and counties should expect further operational instructions issued by the Department via letters, notices, or bulletins rather than formal regulations.
- Implementation of several provisions (including address reporting and retroactive authorization timing) is gated on the director's written determination to the Department of Finance.
Key Definitions
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