§ 15926. — 15926. (Amended by Stats. 2025, Ch. 374, Sec. 4.)

California § 15926.

• Jurisdiction: California
• Code WIC: Welfare and Institutions Code - WIC
• Div. 9.: DIVISION 9. PUBLIC SOCIAL SERVICES
• Part 3.8.: PART 3.8. HEALTH CARE REFORM ELIGIBILITY, ENROLLMENT, AND RETENTION PLANNING ACT

Text

(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.
(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), 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)
The application shall be tested and operational by the date as required by the federal Secretary of Health and Human Services.
(4)
The application form shall, to the extent not inconsistent with federal statutes, regulations, and guidance, satisfy all of the following criteria:
(A)
The form shall include simple, user-friendly language and instructions.
(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)
The form may require only information necessary to support the eligibility and enrollment processes for insurance affordability programs.
(D)
The form may be used for, but shall not be limited to, screening.
(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)
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)
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 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)
An applicant or recipient shall have their information electronically verified in the manner required by the PPACA
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.
(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 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.
(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 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, 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 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)
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 and other federal and state laws are incorporated and followed, including responses to security breaches.

Legislative History

Amended by Stats. 2025, Ch. 374, Sec. 4. (AB 543) Effective January 1, 2026.