Part 3.8HEALTH CARE REFORM ELIGIBILITY, ENROLLMENT, AND RETENTION PLANNING ACT

Section § 15925

Explanation

This law, called the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, outlines a strategy for planning and developing California's health care eligibility and enrollment systems based on federal guidelines under the Affordable Care Act. It mandates the California Health and Human Services Agency, alongside various departments and stakeholders, to gather input on improving eligibility and enrollment processes for state health programs such as Medi-Cal.

The plan includes deciding between using federal or state application forms, developing processes for special populations, ensuring instant hospital enrollment for eligible infants, and setting data collection standards. Other considerations involve allowing updates on eligibility information, renewing eligibility based on other public benefits, protecting personal data confidentiality, and enabling health plan selections for recipients. By July 1, 2012, the agency was to report to legislative committees about any necessary policy or legal changes for implementing these systems.

The reporting requirements become inactive as of January 1, 2016.

(a)CA Welfare and Institutions Code § 15925(a) This part shall be known, and may be cited, as the Health Care Reform Eligibility, Enrollment, and Retention Planning Act.
(b)Copy CA Welfare and Institutions Code § 15925(b)
(1)Copy CA Welfare and Institutions Code § 15925(b)(1) The California Health and Human Services Agency, in consultation with the State Department of Health Care Services (department), Managed Risk Medical Insurance Board (MRMIB), the California Health Benefit Exchange (Exchange), the Office of Technology and Solutions Integration, counties, health care service plans, consumer advocates, and other stakeholders shall undertake a planning and development process regarding this part and aspects of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and regulations or guidance issued pursuant to these acts, related to eligibility for, and enrollment and retention in, state health subsidy programs.
(2)CA Welfare and Institutions Code § 15925(b)(2) The planning and development process shall provide stakeholders the opportunity to provide meaningful input into the planning and development of the aspects of eligibility, enrollment, and retention identified in this section. This process shall be completed in time for all of the following to occur:
(A)CA Welfare and Institutions Code § 15925(b)(2)(A) The certification and approval of the eligibility, enrollment, and retention system, as required by PPACA and regulations and guidance issued thereunder.
(B)CA Welfare and Institutions Code § 15925(b)(2)(B) The approval of enhanced federal funding for Medi-Cal eligibility system development, implementation, and maintenance.
(C)CA Welfare and Institutions Code § 15925(b)(2)(C) The readiness of the eligibility, enrollment, and retention processes to accept and process applications, as required by federal law.
(3)CA Welfare and Institutions Code § 15925(b)(3) The planning and development process shall consider issues, including, but not limited to, all of the following:
(A)CA Welfare and Institutions Code § 15925(b)(3)(A) Whether to use the application developed by the federal Secretary of Health and Human Services, pursuant to Section 1413 of the PPACA (42 U.S.C. Sec. 18083), or whether to develop a separate state form.
(B)CA Welfare and Institutions Code § 15925(b)(3)(B) What process to use for Medi-Cal eligibility determinations for non-Modified Adjusted Gross Income (MAGI) populations, including whether to develop a supplemental application form and how the applications will be processed.
(C)CA Welfare and Institutions Code § 15925(b)(3)(C) Whether to adopt a process for hospitals to enroll infants deemed eligible for Medi-Cal under Section 1396a(e)(4) of Title 42 of the United States Code or the Healthy Families Program under Section 12693.70 of the Insurance Code immediately online, without an application.
(D)CA Welfare and Institutions Code § 15925(b)(3)(D) What data collection standards to utilize for the collection of race, ethnicity, primary language, and disability status.
(E)CA Welfare and Institutions Code § 15925(b)(3)(E) Whether to create a process to allow recipients to provide an update to eligibility information in between renewal dates and to have the option to renew eligibility at the time of the update, resetting the renewal date.
(F)CA Welfare and Institutions Code § 15925(b)(3)(F) Whether to renew eligibility for a state health subsidy program based on information from a public benefits program, if the recipient is otherwise eligible.
(G)CA Welfare and Institutions Code § 15925(b)(3)(G) Protections for the confidentiality of personal information.
(H)CA Welfare and Institutions Code § 15925(b)(3)(H) What process to use to enable applicants determined eligible for and recipients of a state health subsidy program to choose a health plan, if applicable.
(4)CA Welfare and Institutions Code § 15925(b)(4) The agency shall provide the appropriate fiscal and policy committees of the Legislature with information reflecting the process conducted pursuant to paragraph (1) by July 1, 2012, regarding policy and statutory changes needed to develop and implement the eligibility, enrollment, and retention system for health coverage in compliance with this part.
(c)CA Welfare and Institutions Code § 15925(c) The information reporting requirement imposed under paragraph (4) of subdivision (b) is inoperative on January 1, 2016, pursuant to Section 10231.5 of the Government Code.
Health Care Reform Eligibility and Enrollment Medi-Cal Patient Protection and Affordable Care Act Managed Risk Medical Insurance Board California Health Benefit Exchange Affordable Care Act health subsidy programs stakeholder input Medi-Cal eligibility federal funding application forms hospital enrollment data standards confidentiality protections health plan selection policy changes legislative reporting
(Amended by Stats. 2023, Ch. 43, Sec. 71. (AB 120) Effective July 10, 2023.)

Section § 15926

Explanation

This section outlines the processes and requirements for applying to insurance affordability programs in California. These programs include Medi-Cal, the Children's Health Insurance Program (CHIP), and others provided through the California Health Benefit Exchange. Applications can be submitted in person, by mail, over the phone, or online, and must be simple and accessible, especially for individuals with disabilities or limited English proficiency.

A standardized application form will be used, and eligibility should be granted immediately where possible. Applicants have rights to submit self-attested information and must be informed of requirements and penalties, like those for failing to maintain essential health coverage. The law aims to streamline eligibility rules across programs, reduce unnecessary paperwork, and ensure continuous coverage transitions.

Special procedures are in place for renewals and for applicants moving between programs, including referrals to county health programs if not eligible for others. The coordination among state departments ensures that the systems comply with privacy laws, and stakeholders can provide input on system improvements regularly.

(a)CA Welfare and Institutions Code § 15926(a) The following definitions apply for purposes of this part:
(1)CA Welfare and Institutions Code § 15926(a)(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)CA Welfare and Institutions Code § 15926(a)(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)CA Welfare and Institutions Code § 15926(a)(3) “Insurance affordability program” means a program that is one of the following:
(A)CA Welfare and Institutions Code § 15926(a)(3)(A) The Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(B)CA Welfare and Institutions Code § 15926(a)(3)(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)CA Welfare and Institutions Code § 15926(a)(3)(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.
(4)CA Welfare and Institutions Code § 15926(a)(4) 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)CA Welfare and Institutions Code § 15926(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.
(c)Copy CA Welfare and Institutions Code § 15926(c)
(1)Copy CA Welfare and Institutions Code § 15926(c)(1) A single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs shall be developed by the department in consultation with MRMIB and 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)CA Welfare and Institutions Code § 15926(c)(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), and 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.
(3)CA Welfare and Institutions Code § 15926(c)(3) The application shall be tested and operational by the date as required by the federal Secretary of Health and Human Services.
(4)CA Welfare and Institutions Code § 15926(c)(4) The application form shall, to the extent not inconsistent with federal statutes, regulations, and guidance, satisfy all of the following criteria:
(A)CA Welfare and Institutions Code § 15926(c)(4)(A) The form shall include simple, user-friendly language and instructions.
(B)CA Welfare and Institutions Code § 15926(c)(4)(B) The form may not ask for information related to a nonapplicant that is not necessary to determine eligibility in the applicant’s particular circumstances.
(C)CA Welfare and Institutions Code § 15926(c)(4)(C) The form may require only information necessary to support the eligibility and enrollment processes for insurance affordability programs.
(D)CA Welfare and Institutions Code § 15926(c)(4)(D) The form may be used for, but shall not be limited to, screening.
(E)CA Welfare and Institutions Code § 15926(c)(4)(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)CA Welfare and Institutions Code § 15926(c)(4)(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)CA Welfare and Institutions Code § 15926(c)(4)(G) Until January 1, 2016, the department shall instruct counties to not reject an application that was in existence prior to January 1, 2014, but to accept the application and request any additional information needed from the applicant in order to complete the eligibility determination process. The department shall work with counties and consumer advocates to develop the supplemental questions.
(d)CA Welfare and Institutions Code § 15926(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)CA Welfare and Institutions Code § 15926(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)Copy CA Welfare and Institutions Code § 15926(f)
(1)Copy CA Welfare and Institutions Code § 15926(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 his or her 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)CA Welfare and Institutions Code § 15926(f)(2) All insurance affordability programs may accept self-attestation, instead of requiring an individual to produce a document, for age, date of birth, family size, household income, state residence, pregnancy, 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)CA Welfare and Institutions Code § 15926(f)(3) An applicant or recipient shall have his or her information electronically verified in the manner required by the PPACA and implementing federal regulations and guidance and state law.
(4)CA Welfare and Institutions Code § 15926(f)(4) Before an eligibility determination is made, the individual shall be given the opportunity to provide additional eligibility information and to correct information.
(5)CA Welfare and Institutions Code § 15926(f)(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.
(6)CA Welfare and Institutions Code § 15926(f)(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 he or she otherwise qualifies until a determination is made that he or she 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)CA Welfare and Institutions Code § 15926(g) The eligibility, enrollment, and retention system shall offer an applicant and recipient assistance with his or her 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)Copy CA Welfare and Institutions Code § 15926(h)
(1)Copy CA Welfare and Institutions Code § 15926(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 his or her application, renewal, or transfer to another program at any time, and the information shall be promptly provided when requested.
(2)CA Welfare and Institutions Code § 15926(h)(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 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, he or she shall be determined eligible for that program.
(3)CA Welfare and Institutions Code § 15926(h)(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.
(4)CA Welfare and Institutions Code § 15926(h)(4) An applicant who is not eligible for an insurance affordability program for a reason other than income eligibility, 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 referred to the county health coverage program in his or her county of residence.
(i)CA Welfare and Institutions Code § 15926(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)CA Welfare and Institutions Code § 15926(i)(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)CA Welfare and Institutions Code § 15926(i)(2) The applicant shall be informed of the penalty for failure to have minimum essential health coverage.
(j)CA Welfare and Institutions Code § 15926(j) The department shall, in coordination with MRMIB and 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, and self-attestation and verification requirements.
(k)Copy CA Welfare and Institutions Code § 15926(k)
(1)Copy CA Welfare and Institutions Code § 15926(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)CA Welfare and Institutions Code § 15926(k)(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)CA Welfare and Institutions Code § 15926(l) The department, the California Health and Human Services Agency, MRMIB, and the Exchange board shall establish a process for receiving and acting on stakeholder suggestions regarding the functionality of the eligibility systems supporting 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 or enhancements of the eligibility systems. The process shall also include regular updates on the work to analyze, prioritize, and implement corrections to confirmed defects and proposed enhancements, and to monitor screening.
(m)CA Welfare and Institutions Code § 15926(m) In designing and implementing the eligibility, enrollment, and retention system, the department, MRMIB, and the Exchange board shall ensure that all privacy and confidentiality rights under the PPACA and other federal and state laws are incorporated and followed, including responses to security breaches.
(n)CA Welfare and Institutions Code § 15926(n) Except as otherwise specified, this section shall be operative on January 1, 2014.
insurance affordability programs Medi-Cal Children's Health Insurance Program California Health Benefit Exchange application process accessibility limited English proficiency electronic application self-attestation eligibility determination health coverage transition renewal procedures privacy and confidentiality language access stakeholder input
(Amended by Stats. 2013, 1st Ex. Sess., Ch. 3, Sec. 26. (AB 1 1x) Effective September 30, 2013. Section initially operative on January 1, 2014, pursuant to subd. (n).)