Medi-Cal: cost sharing and accessibility.

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.