DraftCalifornia Department of Health Care ServicesPolicy N/A

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.

Policy Summary

PayerCalifornia Department of Health Care Services

PolicyMedi‑Cal eligibility redetermination and community engagement requirements

Policy CodePolicy N/A

Change TypeMultiple operational revisions including semiannual redeterminations, community engagement requirement, premiums and retroactive coverage adjustments

Effective DateJan 1, 2027

Next Review DateN/A

Key ActionCounties must perform eligibility redeterminations every 6 months for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII) (effective no sooner than Jan 1, 2027).

SourceLink

POLICY UPDATE CHANGES

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.

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DraftCalifornia Department of Health Care ServicesPolicy N/A

Medi‑Cal eligibility redetermination and community engagement requirements

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Know when California Department of Health Care Services releases new policies or updates existing guidance.

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Policy Summary

PayerCalifornia Department of Health Care Services

PolicyMedi‑Cal eligibility redetermination and community engagement requirements

Policy CodePolicy N/A

Change TypeMultiple operational revisions including semiannual redeterminations, community engagement requirement, premiums and retroactive coverage adjustments

Effective DateJan 1, 2027

Next Review DateN/A

Key ActionCounties must perform eligibility redeterminations every 6 months for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII) (effective no sooner than Jan 1, 2027).

SourceLink

POLICY UPDATE CHANGES

Introduces a new statutory community engagement requirement as a condition of eligibility for 'applicable individuals' (certain adults) beginning no sooner than January 1, 2027.

Specifies allowed contact and submission methods (internet, phone, mail, in person, electronic means) and acceptance of electronic/telephonic signatures under penalty of perjury.

6 monthsredetermination interval

80 hrscommunity engagement threshold

30 daysnotice cure period

$30monthly premium (when imposed)

90 daysnonpayment grace

1/2/3 moretroactive windows

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):

Applies to individuals defined as 'applicable individuals' under the statute (eligible under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII), generally age 19–64, not pregnant, not entitled to Medicare Part A/B except as excluded by statute).

Timing: Requirement may be enforced no sooner than January 1, 2027 (subject to implementation gating).

Demonstration period at application and between determinations: An applicable individual who applies must demonstrate community engagement for the one month immediately preceding the month of application; an enrolled applicable individual must demonstrate community engagement for one month during the period between their most recent determination (or redetermination) and their next regularly scheduled redetermination as described in Section 14005.37.

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).

If verification fails, county must provide notice of noncompliance and a 30‑calendar‑day cure period during which Medi‑Cal services continue; if no satisfactory showing is provided, denial or disenrollment shall occur no later than the end of the month following the 30‑day period.

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):

Redetermination interval: General rule is annual redeterminations for beneficiaries; effective no sooner than January 1, 2027, counties must perform redeterminations once every 6 months (semiannual) for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII), including state‑funded coverage; other beneficiaries remain on 12‑month cycle unless otherwise specified.

Ex parte and file searches: Counties must gather available information from beneficiary files and program databases (including Medi‑Cal, CalWORKs, CalFresh and applicable federal sources) prior to contacting the beneficiary to determine continued eligibility.

Prepopulated renewal forms: If county cannot determine continued eligibility ex parte, it must send a prepopulated annual or semiannual renewal form at least 60 days before the redetermination date; the form must identify additional information needed and inform the beneficiary to provide required information within 60 days. The form shall allow response by internet, mail, telephone, in person, or other commonly available electronic means where available.

Signatures and outreach: If beneficiary returns the form in person, by phone, online, mail, or other electronic means, the beneficiary must sign the form for it to be considered complete; electronic, telephonic, and handwritten signatures transmitted electronically are accepted. Counties shall attempt contact via the beneficiary's preferred contact method when known.

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):

Tiered eligibility by immigration status and residence: Persons who are not U.S. citizens or nationals are eligible for full‑scope Medi‑Cal benefits only to the extent permitted by federal law; individuals without qualifying immigration status (or not residents of a U.S. state/DC/territory as required by federal law) are limited to emergency medical services and medically necessary pregnancy‑related services unless and until they meet qualifying criteria.

Implementation gating: Paragraphs limiting or expanding benefits (including October 1, 2026 and other dates) shall be implemented only after the Director determines systems have been programmed and communicates that determination in writing to the Department of Finance.

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.

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):

Monthly premium requirement: No sooner than July 1, 2027 (subject to implementation gating), many individuals described in the relevant subdivisions shall be required to pay a monthly premium as a condition of eligibility for full‑scope Medi‑Cal; the premium amount is $30 per beneficiary per month.

Exemptions from premiums and service limitations: The monthly premium and associated service limitations do not apply to individuals under 19 years of age, individuals over 59 years of age, pregnant individuals, nonminor dependents (as defined in Section 11400), and individuals who but for their immigration status are eligible under Section 14005.28; nonminor dependents and those individuals remain eligible for full scope benefits until their 26th birthday.

Nonpayment and grace period: An individual required to pay premiums who does not pay for no more than 90 days will be limited to medically necessary pregnancy‑related services and emergency services; all outstanding premium balances must be paid in full to regain full‑scope Medi‑Cal coverage.

Dental limitations: No sooner than July 1, 2026, individuals 19 and older in certain specified cohorts are not eligible for dental services except for emergency dental care, with exceptions for nonminor dependents and certain immigration‑status exceptions up to age 26.

Billing, Codes, and Key Numeric Parameters

Regulatory changes (no billing/coding rules)mixed

N/A	This document amends state law; no clinical/coding lists provided in this part.

Billing/Coding impactmixed

No explicit procedure or billing codes are specified in this part of the document.

No codes specified in this excerptmixed

No codes listed

inv-08: Community engagement hourly threshold — 80 hours per month.

Monthly hourly requirement80 hours per month (may be a combination of work, community service, work program participation, or half‑time education totaling at least 80 hours)

Acceptable activity: community serviceComplete no less than 80 hours of community service in the month

Acceptable activity: work programParticipate in a work program for no less than 80 hours in the month

Acceptable activity: educationBe enrolled at least half‑time in an educational program as defined in the Higher Education Act/Carl D. Perkins Act

Acceptable activity: earnings thresholdHave total monthly income equal to or exceeding applicable minimum wage × 80 hours

County and Provider Operational Requirements

Documentation Required

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.

Documentation Required

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.

Key Definitions

inv-18: 'Applicable individual' definition referencing 42 U.S.C. §1396a(a)(10)(A)(i)(VIII).

Statutory reference42 U.S.C. §1396a(a)(10)(A)(i)(VIII)

Age and status limitsIndividual has attained age 19 and is under 65, is not pregnant, and is not entitled to or enrolled for Medicare Part A or B

ExclusionsExcludes 'specified excluded individuals' defined in subdivision (a)(2) of Section 14005.69 (e.g., certain Indians, veterans with disability, parents/caregivers of young children, medically frail)

inv-19: 'MAGI-based financial methods' definition (income methodologies per federal statute).

Definition sourceIncome calculated using methodologies in 42 U.S.C. §1396a(e)(14) as added by the ACA and subsequent amendments

Common nameReferred to in policy as 'MAGI‑based financial methods'

Policy Summary

PayerCalifornia Department of Health Care Services

PolicyMedi‑Cal eligibility redetermination and community engagement requirements

Policy CodePolicy N/A

Change TypeMultiple operational revisions including semiannual redeterminations, community engagement requirement, premiums and retroactive coverage adjustments

Effective DateJan 1, 2027

Next Review DateN/A

Key ActionCounties must perform eligibility redeterminations every 6 months for individuals enrolled under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII) (effective no sooner than Jan 1, 2027).

SourceLink

On This Page

Change‑of‑circumstances redeterminations: For redeterminations triggered by a change in circumstances, the county shall only request information related to that change and must give the beneficiary 30 days to respond to such a request; if the redetermination purpose is loss of contact and mailed forms are returned as undeliverable, that return triggers immediate notice of action terminating Medi‑Cal eligibility.

Response timeframes and termination: For annual/semiannual renewals, beneficiaries have 60 days to return prepopulated renewal forms; failure to respond within 60 days (after timely notice) permits termination. For change‑of‑circumstance redeterminations, beneficiaries have 30 days to respond; failure after required contacts results in a 10‑day termination notice. Eligibility continues while redetermination is pending until the county issues a determination consistent with due process.

Disability considerations: Department, counties, consumer representatives, and eligibility workers shall develop timeframes and consumer‑friendly procedures for disability‑based redeterminations, including ex parte review and accommodations to allow reasonable opportunity to submit medical records and other documentation.

Accessibility and language: Renewal forms and notices must be accessible to persons with limited English proficiency and persons with disabilities consistent with federal and state requirements.

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.

Premiums and nonpayment consequences: For specified noncitizen cohorts, no sooner than July 1, 2027 (or as otherwise phased), a monthly premium of $30 per beneficiary may be imposed as a condition of eligibility for full‑scope Medi‑Cal; after no more than 90 days of nonpayment, eligibility is limited to medically necessary pregnancy‑related services and emergency services until outstanding balances are paid in full.

Documentation and verification: Applicants or beneficiaries without declared lawful permanent resident or similar status are given a reasonable opportunity (30 days) to submit evidence of immigration status; verification is performed as required for federal financial participation, using USCIS where applicable, with privacy protections for verification data.

Dental service limitations: No sooner than July 1, 2026, individuals 19 years of age or older in certain noncitizen cohorts shall not be eligible for dental services except emergency dental care, with exceptions for nonminor dependents and the specified immigration‑status exceptions up to age 26.

Address collection and plan reporting: The State shall regularly obtain enrollee address information from reliable sources (e.g., USPS, NCOA); managed care plans must promptly transmit to counties any enrollee address information provided by or verified directly with the individual (requirement effective Jan 1, 2027 for establishing regular process).

Implementation condition and director certification: The monthly premium requirements, service limitations, and many other subdivisions are to be implemented only after the director determines systems have been programmed and communicates that determination in writing to the Department of Finance; the Department may implement or specify these provisions via plan/county letters, information notices, or bulletins without further rulemaking.

Verification privacy and process: Immigration status verification shall be subject to privacy protections and performed using USCIS to the extent required for federal financial participation; individuals are given reasonable opportunity (30 days) to provide documentation when required.

inv-09: Premium amount — $30 per beneficiary per month.

Monthly premium amount$30 per beneficiary per month

Effective gatingPremiums imposed no sooner than specified dates and subject to director/system readiness determinations

ExemptionsIndividuals under 19, over 59, and pregnant individuals are not subject to the monthly premium

inv-10: monthly_premium_amount numeric value.

monthly_premium_amount (numeric)30

CurrencyUSD (dollars per month)

Applies toSpecified noncitizen cohorts and others described in section when implemented

inv-11: nonpayment_grace_period_days numeric value.

nonpayment_grace_period_days (numeric)90

Consequence after grace periodCoverage limited to medically necessary pregnancy‑related services and emergency services until outstanding premiums are paid

Restoration conditionAll outstanding premium balances must be paid in full to regain full‑scope Medi‑Cal benefits

Notice must describe how to make a satisfactory showing and outline reapplication and hearing rights.

Documentation Required

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.

Denial Risk

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).

Prior Authorization

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.

Note

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.

ScopeUsed for determining household income and eligibility under MAGI rules

inv-20: Additional notes on 'applicable individual' and excluded individuals.

Deemed compliance/exemptionsIndividuals under 19, Medicare enrollees, persons described in subclauses (I)–(VII) of 42 U.S.C. §1396a(a)(10)(A)(i), inmates during part of lookback period, and other federally required exemptions are deemed to have demonstrated community engagement

County verification processDepartment shall establish processes to use available reliable information and minimize need for additional documentation when verifying community engagement

Noncompliance cure periodIf county cannot verify engagement, individual gets 30 calendar days from notice receipt to show compliance or exemption; benefits continue during that period

inv-21: 'Reliable data sources' for address verification (USPS forwarding, NCOA, etc.).

USPS returned mail with forwarding addressMail returned to the state by the United States Postal Service with a forwarding address

National Change of Address Database (NCOA)The National Change of Address Database maintained by the United States Postal Service

Managed care entities and plansManaged care entity or prepaid health plans when the enrollee provides or directly verifies address information

inv-22: 'Nonminor dependents' definition reference (Section 11400).

Statutory referenceNonminor dependents as defined in Section 11400

Protection from premiums/service limitsNonminor dependents are exempt from the monthly premium and service limitation provisions and remain eligible for full‑scope benefits until their 26th birthday

Dental services exceptionNonminor dependents are excluded from the dental service limitation for adults 19+

inv-23: 'Immigration‑status eligible individuals' — those eligible but for immigration status per Section 14005.28.

Who they areIndividuals who, but for their immigration status, are eligible for Medi‑Cal pursuant to Section 14005.28

Age‑based exemptionThese individuals remain eligible for full‑scope Medi‑Cal until their 26th birthday and are not subject to monthly premiums or service limitations while under 26

Relation to premiums/service limitsSpecifically exempted from the $30 monthly premium requirement and the post‑nonpayment service limitations described in the section

inv-24: Applicants under 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) — categories and implications for retroactive coverage.

Applicant categoryApplicants under 42 U.S.C. §1396a(a)(10)(A)(i)(VIII) (including state‑funded coverage)

Retroactive coverage window for this categoryAuthorization for payment limited to the month immediately prior to the month the application was made for applications on/after the first quarter beginning after Dec 31, 2026

Other applicants' windowsOther applicants filing on or after that quarter get authorization for either the two months immediately prior; prior general three‑month rule applies to earlier applications as specified