California Health Benefit Exchange

This document outlines the 2025 California Enhanced Cost-Sharing Reduction Program Design, adopted in accordance with the Budget Act of 2024. The program aims to provide enhanced cost-sharing reductions to eligible return filers through Silver 94, 87, and 73 qualified health plans based on household income. It details eligibility requirements, including applying through the Exchange and meeting federal cost-sharing reduction criteria with specific income level exceptions. The design also specifies the mechanism for interim payments to qualified health plan issuers to compensate for the enhanced benefits.

The 2026 California Premium Subsidy Program Design outlines the state advance premium assistance subsidies for eligible return filers. It details the calculation of state advance premium assistance amounts, eligibility requirements for recipients, and provides definitions for key terms such as 'applicable percentage,' 'household income,' and 'federal poverty level.' The program aims to provide financial assistance for health coverage through the Exchange by supplementing federal premium tax credits, and it specifies the reconciliation process for subsidies based on projected versus actual income and family size.

The board meeting commenced with the Chair calling the meeting to order and confirming the quorum. Discussions covered updates on board meeting dates, noting the cancellation of the February meeting and scheduling the next meeting for March 19th due to a board member departure. Key agenda items included an overview of open enrollment data, which showed plan selections level with the previous record year, and observed warning signs such as an increase in consumer cancellations, particularly among middle-income Californians losing enhanced premium tax credits, leading to an 18% cancellation rate in that demographic. There was also a significant shift towards lower-premium, higher-deductible Bronze plans. A major segment addressed program integrity and fraud, comparing Covered California's robust controls, such as mandatory consumer consent for delegate actions and active monitoring, against issues noted in a GAO report concerning the federal marketplace (healthcare.gov). It was emphasized that Covered California has received no complaints regarding unauthorized enrollments without consumer knowledge.

The annual tribal consultation meeting, organized by Covered California's External Affairs Division, focused on updates and dialogue with tribal representatives and organizations. Key discussion points included American Indian and Alaskan Native enrollment figures, which reached a record high of 8,082 members from federally recognized tribes. The executive director provided updates on community engagement efforts, including a recent virtual meeting with the Southern California Tribal Chairmen's Association. The meeting covered planned policy updates and information from the Equity and Quality Transformation Division. Participants also discussed preparations for the 2025 Open Enrollment, noting that health plan rates are increasing by an average of 7.9% due to rising healthcare service utilization and costs, though financial assistance mitigates the impact for many consumers. Changes in dental plan offerings were also presented, including the addition of Humana and the exit of Dental Health Services in Region 9. The session included open forums for health plan questions and general tribal feedback.

The meeting addressed legislative actions taken in California, specifically AB44 and SB 105, focusing on ensuring access to gender-affirming care through a $15 million appropriation from the Healthcare Affordability Reserve Fund, despite contrary federal rules. The board also discussed provisions in AB44 securing coverage for CDC/ACIP-recommended immunizations based on evidence-based scientific recommendations. Discussions covered access to reproductive health care services, including abortion services, and the transfer of segregated funds related to the $1 per member per month non-subsidized charge. Furthermore, the report detailed federal developments concerning the extension of enhanced tax credits, with ongoing negotiations in Congress impacting marketplace affordability and operational planning for open enrollment. A judicial stay blocking several provisions of the CMS final rule was noted, though the provision regarding gender-affirming care and the end of eligibility for DACA recipients were not stayed. CMS guidance on making catastrophic plans more readily available due to potential affordability decreases was also reviewed. Finally, the board provided comments on proposed changes to the NCQA's health equity accreditation program and submitted joint comments on the 2026 Medicare physician fee schedule proposal.