Insurance Affordability Programs Eligibility Appeals

This dataset includes the number of individuals who have filed an appeal for a subsidized Covered California Qualified Health Plan (QHP), Medi-Cal, or a combination of both eligibility determinations by year and quarter. Appeals may be filed by an appellant for determinations that resulted in a denial, eligibility, or discontinuance of coverage. A denial is defined as an eligibility determination at application that resulted in a denial of coverage. An appeal regarding an eligibility determination may be filed when the appellant disputes the type of program eligibility. A discontinuance is when an individual is no longer eligible for Medi-Cal or Covered California QHP. Appeals may be filed for cases involving mixed determinations, such as when household members applied for and/or had eligibility determinations made for the two programs (i.e., parents were eligible for Covered California and the child(ren) were eligible for Medi-Cal). Covered California and Medi-Cal eligibility appeals are processed and adjudicated by Administrative Law Judges and the California Department of Social Services (CDSS) staff who track appeals and hearing results. This dataset is part of the public reporting requirements set forth in California Welfare and Institutions Code 14102.5(a)(6).

Data and Resources

Additional Info

Field Value
Contact Email [email protected]
Program Medi-Cal Eligibility Division / Program Review Branch / Data Analytics Section
Homepage URL [email protected]
Temporal Coverage

2016 Quarter 1 to 2023 Quarter 4

Spatial/Geographic Coverage

California

Geographic Granularity Statewide
Language English (EN)
Frequency Quarterly
De-Identification Method

http://www.dhcs.ca.gov/dataandstats/Pages/PublicReportingGuidelines.aspx

Data Collection Tool

CDSS Appeals Case Management System

License Terms of Use
Limitations Use of this data is subject to the CHHS Terms of Use and any copyright and proprietary notices incorporated in or accompanying the individual files.
Additional Limitations

Some presented eligible counts are considered preliminary and subject to change. Eligibility for Medi-Cal may occur retroactively and it may take time for eligibility determinations to be processed and reported to DHCS. As such, eligibility data is approximately 96% complete for the current month, 98% complete within one month, and over 99% complete within 2 months. Eligibility counts for a specific month are considered complete for statistical reporting purposes 12 months after the month’s end.

Last Updated March 6, 2024, 22:30 (UTC)