A BIG, BEAUTIFUL TURD
For one in four Mono County residents relying on Medi-Cal, the safety net is tightening, and county officials are struggling to respond.
Over the next three years, federal and state policy changes are expected to reshape health coverage, potentially requiring hundreds of local residents to complete new paperwork, face stricter eligibility rules, incur additional costs, or lose coverage altogether.
In response, the county plans to revise its own programs to prepare for a surge in demand for county-provided healthcare services.
During Tuesday’s Board of Supervisors meeting, Health and Human Services Director Kathryn Peterson outlined the coming changes, joined by Kari Brownstein, executive director of the Mono County Medical Services Program (CMSP).
The changes stem from the federal “Big Beautiful Bill” (H.R. 1), signed in July 2025 by President Donald Trump, along with provisions in California’s 2026 state budget.
Some of these policies have already taken effect.
For one thing, as of the new year, eligibility for traditional Medi-Cal is no longer based on income alone for seniors and people with disabilities. County workers are now required to consider savings accounts, cash on hand, and certain property when determining whether someone qualifies.
The cap is firm at $130,000 in assets for an individual, plus $65,000 for each additional household member, excluding a primary home, one vehicle, household items, and some retirement accounts.
These asset tests are an old policy that was suspended in recent years and is now returning. As a result, Peterson estimates that 450 to 500 Mono County residents could be affected.
Also, on Jan. 1, the “Beautiful Bill” narrowed options for immigrants. Adults without “Satisfactory Immigration Status” (meaning a citizenship, green card, or non-citizen status) will no longer be able to enroll in full Medi-Cal.
Those already enrolled can keep their benefits, provided they complete renewals on time and continue to meet income and California residency requirements. But if coverage lapses, they have a three-month window to re-enroll.
After that three-month window closes, affected individuals may qualify only for restricted-scope Medi-Cal, which only covers emergency services, pregnancy-related care, and nursing home services. Routine doctor visits, specialty care, and ongoing treatment would no longer be covered.
Then, on July 1, Medi-Cal members subject to the new immigration rules will lose full dental coverage. They will retain emergency dental benefits, but routine cleanings, fillings, and preventive services will likely not be covered.
Peterson estimates that another 450 to 500 Mono County residents could be affected by these changes.
Further pressure on immigrants is expected Oct. 1, when the federal government revises how it classifies certain immigration categories, potentially ruling out refugees, asylees, humanitarian parolees, and survivors of violence with pending cases. However, state guidance on this item is still forthcoming, and Peterson said they do not yet know how many residents could be affected.
But the most dramatic changes are expected to arrive in 2027.
Beginning Jan. 1, adults enrolled through the Affordable Care Act expansion (which applies to adults under age 65 with incomes up to 138% of the federal poverty level, a federal income measure defining who qualifies as low income) will face new employment requirements.
Under the “Beautiful Bill,” these people must document at least 80 hours per month of work, job training, education, or volunteer service, or meet a minimum income threshold to maintain coverage.
“This is a big one,” Peterson said.
Adults in the expansion group must verify eligibility every six months instead of annually. Missing a deadline may result in loss of coverage, putting roughly 1,000 to 1,500 Mono residents on a far more frequent renewal cycle.
Retroactive coverage will shrink. Medi-Cal currently covers up to three months of medical bills incurred before someone files an application. Starting in 2027, Medi-Cal will limit this to one month for adults without children and two months for other groups.
Financial obligations will follow.
Beginning July 1, 2027, some Medi-Cal members will be required to pay a small monthly premium to maintain full coverage. If the premium is not paid, coverage will shift to emergency-only benefits. Mono County estimates that 500 or fewer residents may be affected.
Then, beginning Oct. 1, 2028, some adults may face copayments for some non-emergency services, such as “seeing a specialist doctor, cardiologist, dermatologist,” or getting certain tests.
The laws cap copays at 5% of annual household income. These do not apply to emergency care, preventive services, prenatal care, pediatric care, mental health treatment, substance use services, or care at community health centers or rural health clinics.
Still, Peterson estimates that 400 or fewer Mono County residents could see new out-of-pocket costs.
As Medi-Cal eligibility tightens, county officials are preparing for possible increases in enrollment in the County Medical Services Program (CMSP), a program so old and underutilized that many residents may not remember it.
Established in 1983 after California eliminated Medi-Cal eligibility for medically indigent adults, CMSP serves as a pooled-risk health benefit program for smaller counties with populations under 300,000.
Before the Affordable Care Act expanded Medi-Cal in 2014, CMSP was the primary indigent healthcare program for participating counties.
After the ACA expansion, more than 90% of CMSP members transitioned to Medi-Cal coverage, and enrollment dropped sharply. In Mono County, active CMSP users fell from roughly 215–250 in fiscal year 2011–12 to fewer than 10 by 2019–20.
Program director Brownstien anticipates roughly 100 residents could seek CMSP coverage after losing Medi-Cal or Covered California subsidies.
CMSP exists under state law requiring counties to provide medically necessary care to indigent residents as a provider of last resort. The program helps counties meet that obligation, but it does not eliminate county responsibility.
While CMSP maintains a fund balance, Brownstein said that rising enrollment could strain resources over time.
Because of this, CMSP’s governing board is already considering how to scale the program back to manage potential enrollment surges.
“What happens when our program’s larger and we have larger expenses, and we don’t have the revenues?” Brownstien posed.
County participation fees, currently waived, could be reinstated. Mono County’s fee, if reinstated, would total approximately $25,469 annually.
She plans to bring more changes and updates to the program for the board to consider in May.
