Article 1.2. Protect the Promise Act
14042.5.
(a) This article shall be known, and may be cited, as the Protect the Promise Act.
(b) It is the intent of the Legislature that this article strengthen the Medi-Cal program by enforcing eligibility verification, mandating the use of existing data, stopping improper payments, and safeguarding taxpayer dollars for Californians who truly qualify for care under the Medi-Cal program.
14042.51.
(a) The department, in coordination with counties, shall verify Medi-Cal eligibility before enrollment approval whenever reliable data sources are available.
(b) Subject to any exceptions available for limited circumstances under Section 435.952 of Title 42 of the Code of Federal Regulations or any other applicable federal law, self-attestation alone for Medi-Cal eligibility purposes shall not be accepted for any of the following eligibility factors:
(1) Income.
(2) Residency.
(3) Identity.
(4) Household composition.
(5) Citizenship or immigration status.
(c) The department shall ensure that an applicant’s information is supported by documentary evidence and verified data sources to comply with federal and state eligibility standards.
14042.52.
(a) (1) For purposes of Medi-Cal eligibility determinations and redeterminations, the department and the county shall fully utilize the data sets and verification systems listed in this section.
(2) On at least a monthly basis, the department shall cross-reference beneficiary data with national Medicaid enrollment databases through the federal Centers for Medicare and Medicaid Services (CMS) to identify and resolve duplicate enrollments.
(3) The department shall complete a one-time submission of all federally required enrollment data to CMS no later than October 1, 2029.
(4) On at least a quarterly basis, the department shall review information from all of the following sources:
(A) The federal Social Security Administration, including records of earned income, incarceration, Supplemental Security Income, beneficiary status, pensions, and the Death Master File.
(B) The United States Department of Health and Human Services, including the National Directory of New Hires and child support enforcement data.
(C) The United States Department of Housing and Urban Development regarding income and housing assistance payments.
(D) The Federal Bureau of Investigation regarding national fleeing felon information.
(E) The Department of Corrections and Rehabilitation regarding state incarceration status.
(F) The Employment Development Department and the Franchise Tax Board concerning fluctuations in employment or wages.
(5) On an annual basis, the department shall review data provided by the Franchise Tax Board and the federal Internal Revenue Service, including tax-filing history, adjusted gross income, and household composition.
(b) (1) The department shall maintain a continuous process to identify changes in residency. The department shall receive, track, and act upon address change information as it becomes available from all of the following sources:
(A) The National Change of Address system of the United States Postal Service (USPS).
(B) Returned mail tracked through USPS.
(C) Address files and updated contact information provided by managed care organizations.
(2) The department shall implement the residency verification streams described in paragraph (1) commencing on January 1, 2027.
14042.53.
(a) The department shall require regular and systematic eligibility redeterminations, consistent with federal law.
(b) The department shall do all of the following:
(1) Unless prohibited by federal law, conduct eligibility redeterminations at least once every six months for all nonelderly adult Medi-Cal beneficiaries eligible under Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code, without applying to individuals described in Section 1396a(xx)(9)(A)(ii)(II) of that title.
(2) Conduct eligibility redeterminations for all other beneficiaries at least once every 12 months.
(3) Prohibit indefinite or automatic renewals without verification.
(4) Require redeterminations to be triggered by data changes identified in Section 14042.52, not solely by periodic review.
(5) Require immediate corrective action when discrepancies are confirmed.
(c) The department shall implement this section commencing on January 1, 2027.
14042.54.
The department and the county shall do all of the following:
(a) Promptly identify eligibility errors.
(b) Correct confirmed errors within 30 calendar days upon discovery of the error, to the extent permitted by federal law.
(c) Prevent continued payments to ineligible individuals.
(d) Recover improper payments, as permitted by federal law.
14042.55.
(a) The department shall establish enforceable accountability mechanisms, including all of the following:
(1) Annual public reporting to the Legislature, in accordance with Section 9795 of the Government Code, on all of the following:
(A) Eligibility error rates.
(B) Number of cases flagged and resolved.
(C) Amount of improper payments prevented or recovered.
(D) Compliance failures and corrective actions.
(2) Development of timelines to address weaknesses in eligibility determinations or redeterminations, as discussed in reports by the California State Auditor.
(3) Designation of responsible departmental officials for compliance and remediation.
(b) Failure to demonstrate measurable progress pursuant to this section shall be subject to legislative oversight hearings.
14042.56.
Medi-Cal eligibility practices shall be fully aligned with federal improper payment and eligibility integrity standards in order to reduce the state’s exposure to potential financial penalties.
14042.57.
(a) This article shall be implemented in conjunction with Sections 14005, 14005.37, 14005.39, 14011, and 14013.3, and with any other applicable provisions of law, in a manner ensuring further transparency and accountability for the Medi-Cal eligibility determination and redetermination process.
(b) This article shall be implemented to the maximum extent permitted by federal law. The department shall utilize all authority and flexibility under Subpart J (commencing with Section 435.900) of Part 435 of Subchapter C of Chapter IV of Title 42 of the Code of Federal Regulations, as applicable to income and eligibility verification requirements, and to the extent consistent with any other applicable federal law.