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).