AB 2077: Health Care Eligibility, Enrollment, and Retention Act.
- Session Year: 2015-2016
- House: Assembly
- Latest Version Date: 2016-09-02
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code and a cost-sharing reduction under a specified provision of federal law. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would establish procedures to ensure that eligible recipients of insurance affordability programs move between the Medi-Cal program and other insurance affordability programs without any breaks in coverage as required under the provision described above. The bill would require an individuals case information and eligibility determination to be referred to his or her county of residence within 3 business days if the individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The bill would require those referrals to be processed by the county, as specified, to ensure the individuals Medi-Cal eligibility is effective pursuant to specified timelines.
The bill would generally prohibit, if an individual is eligible to enroll in a qualified health plan through the Exchange, Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility, and would require the notice of action to inform the individual of the date by which he or she must select and enroll in a qualified health benefit plan through the Exchange, as specified. The bill would provide that this provision shall only be implemented to the extent that federal financial participation is available.
By modifying the enrollment process under the Medi-Cal program, thereby increasing the responsibilities of counties in the administration of the Medi-Cal program, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code and a cost-sharing reduction under a specified provision of federal law. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would establish procedures to ensure that eligible recipients of insurance affordability programs move between the Medi-Cal program and other insurance affordability programs without any breaks in coverage as required under the provision described above. The bill would require an individuals case information and eligibility determination to be sent referred to his or her county of residence within 3 business days if the individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The bill would require those cases referrals to be processed by the county according to county, as specified, to ensure the individuals Medi-Cal eligibility is effective pursuant to specified timelines.
The bill would generally prohibit, if an individual is eligible to enroll in a qualified health plan through the Exchange, Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility, and would require the notice of action to inform the individual of the date by which he or she must select and enroll in a qualified health benefit plan through the Exchange, as specified. The bill would provide that this provision shall only be implemented to the extent that federal financial participation is available.
By modifying the enrollment process under the Medi-Cal program, thereby increasing the responsibilities of counties in the administration of the Medi-Cal program, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code and a cost-sharing reduction under a specified provision of federal law. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would establish procedures to ensure that eligible recipients of insurance affordability programs move between the Medi-Cal program and other insurance affordability programs without any breaks in coverage as required under the provision described above. The bill would require an individuals case information and eligibility determination to be sent to his or her county of residence within 3 business days if the individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The bill would require those cases to be processed by the county according to specified timelines. The bill would establish different enrollment procedures to be followed for those counties that provide Medi-Cal services under the two-plan model or the geographic managed care plan model, or a county organized health system, as specified.
The bill would generally prohibit, if an individual is eligible to enroll in a qualified health plan through the Exchange, Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility, and would require the notice of action to inform the individual of the date by which he or she must select and enroll in a qualified health benefit plan through the Exchange, as specified. The bill would provide that this provision shall only be implemented to the extent that federal financial participation is available.
By modifying the enrollment process under the Medi-Cal program, thereby increasing the responsibilities of counties in the administration of the Medi-Cal program, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code and a cost-sharing reduction under a specified provision of federal law. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would establish procedures to ensure that eligible recipients of insurance affordability programs move between the Medi-Cal program and other insurance affordability programs without any breaks in coverage as required under the provision described above. The bill would require, among other things, an individuals case to be run through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERs) if an individual enrolled in a qualified health benefit plan through the Exchange reports a change in circumstances or is reevaluated for eligibility, and there is a change in circumstances affecting his or her eligibility for an insurance affordability program. The bill would require the individuals case file an individuals case information and eligibility determination to be sent to his or her county of residence within 3 business days if CalHEERs receives information indicating that the individual is determined newly eligible for Medi-Cal. The bill would prohibit the county from treating the receipt of a case file under these circumstances as a new Medi-Cal application, and Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The bill would require those case files cases to be processed by the county according to specified timelines. The bill would require the county to issue to those individuals who are newly eligible for Medi-Cal a notice that contains specified information, including instructions on how to select a Medi-Cal managed care health plan. The bill would establish different enrollment procedures to be followed for those counties that provide Medi-Cal services under the two-plan model or the geographic managed care plan model, or a county organized health system, as specified.
The bill would generally prohibit prohibit, if an individual is eligible to enroll in a qualified health plan through the Exchange, Medi-Cal benefits from being terminated until at least 30 20 days after the county sends the notice of action terminating Medi-Cal eligibility, and would require the notice of action to inform the individual of the date by which he or she must select and enroll in a qualified health benefit plan through the Exchange, as specified. The bill would provide that this provision shall only be implemented to the extent that federal financial participation is available.
By modifying the enrollment process under the Medi-Cal program, thereby increasing the responsibilities of counties in the administration of the Medi-Cal program, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code. Code and a cost-sharing reduction under a specified provision of federal law. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would declare the intent of the Legislature to enact legislation that would establish procedures to ensure that individuals move between Medi-Cal and the Exchange without any breaks in coverage as required under the provision described above. establish procedures to ensure that eligible recipients of insurance affordability programs move between the Medi-Cal program and other insurance affordability programs without any breaks in coverage as required under the provision described above. The bill would require, among other things, an individuals case to be run through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERs) if an individual enrolled in a qualified health benefit plan through the Exchange reports a change in circumstances or is reevaluated for eligibility, and there is a change in circumstances affecting his or her eligibility for an insurance affordability program. The bill would require the individuals case file to be sent to his or her county of residence within 3 business days if CalHEERs receives information indicating that the individual is newly eligible for Medi-Cal. The bill would prohibit the county from treating the receipt of a case file under these circumstances as a new Medi-Cal application, and would require those case files to be processed by the county according to specified timelines. The bill would require the county to issue to those individuals who are newly eligible for Medi-Cal a notice that contains specified information, including instructions on how to select a Medi-Cal managed care health plan. The bill would establish different enrollment procedures to be followed for those counties that provide Medi-Cal services under the two-plan model or the geographic managed care plan model, or a county organized health system, as specified.
The bill would generally prohibit Medi-Cal benefits from being terminated until at least 30 days after the county sends the notice of action terminating Medi-Cal eligibility, and would require the notice of action to inform the individual of the date by which he or she must select and enroll in a qualified health benefit plan through the Exchange, as specified.
By modifying the enrollment process under the Medi-Cal program, thereby increasing the responsibilities of counties in the administration of the Medi-Cal program, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.
Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the states childrens health insurance program (CHIP). Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act, and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires an individual to have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means. Existing law defines insurance affordability programs to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a qualified health benefit plan through the Exchange with advance payment of the premium tax credit established under a specified provision of the Internal Revenue Code. During the processing of an application, renewal, or a transition due to a change in circumstances, existing law requires an entity making eligibility determinations for an insurance affordability program to ensure that an eligible applicant and recipient of those programs that meets all program eligibility requirements and complies with all necessary requirements for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
This bill would declare the intent of the Legislature to enact legislation that would establish procedures to ensure that individuals move between Medi-Cal and the Exchange without any breaks in coverage as required under the provision described above.
It is the intent of the Legislature, with the enactment of this act, to establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)Except as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiarys circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c)A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d)Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiarys Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
(1)The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(2)The beneficiary requests that the county determine whether he or she is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e)(1)For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiarys Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiarys file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of his or her immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2)In the case of an annual redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
(A)The eligibility determination and the information it is based on.
(B)That the beneficiary is required to inform the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3)The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4)In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiarys eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f)(1)In the case of an annual eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual renewal form, at least 60 days before the beneficiarys annual redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A)The requirement that he or she provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B)That the beneficiary may respond to the county via the Internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C)That if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
(D)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary via the Internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3)If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate his or her eligibility for Medi-Cal benefits following the provision of timely notice.
(4)If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is not complete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5)(A)The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B)For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g)(1)In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that is prepopulated with the information that the county has obtained and that states the information needed to renew eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means and, if the individual will provide the form by mail or in person, to sign the form. The form shall include a telephone number to call in order to obtain more information. The form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond. Except as provided in paragraph (2), failure to respond prior to the end of this 30-day period shall not impact his or her Medi-Cal eligibility.
(2)If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3)During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h)Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i)If within 90 days of termination of a Medi-Cal beneficiarys eligibility or a change in eligibility status pursuant to this section, the beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined by the county and if the beneficiary is found eligible, or the beneficiarys eligibility status has not changed, whichever applies, the termination shall be rescinded as though the form were submitted in a timely manner.
(j)If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k)The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l)The county shall consider blindness as continuing until the reviewing physician determines that a beneficiarys vision has improved beyond the applicable definition of blindness contained in the plan.
(m)The county shall consider disability as continuing until the review team determines that a beneficiarys disability no longer meets the applicable definition of disability contained in the plan.
(n)In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month eligibility period.
(o)(1)For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs and if the individual is found to be eligible, the county shall, as appropriate, transfer the individuals electronic account to other insurance affordability programs via a secure electronic interface.
(2)If the individual is eligible to enroll in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code, Medi-Cal benefits shall not be terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility. The notice of action shall inform the individual of the date by which he or she must select and enroll in a qualified health plan through the Exchange to avoid being uninsured. This paragraph shall only be implemented to the extent that federal financial participation is available.
(p)Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an Internet Web site identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s)For purposes of this section, MAGI-based financial methods means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
(v)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(w)This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 3.Section 15927 is added to the Welfare and Institutions Code, immediately following Section 15926, to read:15927.(a)If an individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) developed under Section 15926, the individuals case information and eligibility determination shall be referred to his or her county of residence within three business days.
(b)(1)If the referral indicates that an individual is eligible or conditionally eligible for MAGI Medi-Cal, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective according to either of the following timelines, as applicable:
(A)If the referral is received with at least five business days remaining in the month, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective on the first day of the following month.
(B)If the referral is received with less than five business days remaining in the month, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
(2)If the referral requires follow-up to establish Medi-Cal eligibility, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
SEC. 4.If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
It is the intent of the Legislature, with the enactment of this act, to establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)Except as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiarys circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c)A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d)Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiarys Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
(1)The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(2)The beneficiary requests that the county determine whether he or she is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e)(1)For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiarys Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiarys file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of his or her immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2)In the case of an annual redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
(A)The eligibility determination and the information it is based on.
(B)That the beneficiary is required to inform the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3)The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4)In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiarys eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f)(1)In the case of an annual eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual renewal form, at least 60 days before the beneficiarys annual redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A)The requirement that he or she provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B)That the beneficiary may respond to the county via the Internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C)That if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
(D)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary via the Internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3)If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate his or her eligibility for Medi-Cal benefits following the provision of timely notice.
(4)If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is not complete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5)(A)The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B)For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g)(1)In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that is prepopulated with the information that the county has obtained and that states the information needed to renew eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means and, if the individual will provide the form by mail or in person, to sign the form. The form shall include a telephone number to call in order to obtain more information. The form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond. Except as provided in paragraph (2), failure to respond prior to the end of this 30-day period shall not impact his or her Medi-Cal eligibility.
(2)If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3)During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h)Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i)If within 90 days of termination of a Medi-Cal beneficiarys eligibility or a change in eligibility status pursuant to this section, the beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined by the county and if the beneficiary is found eligible, or the beneficiarys eligibility status has not changed, whichever applies, the termination shall be rescinded as though the form were submitted in a timely manner.
(j)If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k)The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l)The county shall consider blindness as continuing until the reviewing physician determines that a beneficiarys vision has improved beyond the applicable definition of blindness contained in the plan.
(m)The county shall consider disability as continuing until the review team determines that a beneficiarys disability no longer meets the applicable definition of disability contained in the plan.
(n)In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month eligibility period.
(o)(1)For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs and if the individual is found to be eligible, the county shall, as appropriate, transfer the individuals electronic account to other insurance affordability programs via a secure electronic interface.
(2)If the individual is eligible to enroll in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code, Medi-Cal benefits shall not be terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility. The notice of action shall inform the individual of the date by which he or she must select and enroll in a qualified health plan through the Exchange to avoid being uninsured. If the individual has effectuated his or her enrollment in a qualified health plan through the Exchange before the termination date specified in the notice, Medi-Cal eligibility shall be terminated as of the date of enrollment in the qualified health plan. This paragraph shall only be implemented to the extent that federal financial participation is available.
(p)Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an Internet Web site identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s)For purposes of this section, MAGI-based financial methods means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
(v)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(w)This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 3.Section 15927 is added to the Welfare and Institutions Code, immediately following Section 15926, to read:15927.(a)If an individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) developed under Section 15926, the individuals case information and eligibility determination shall be sent referred to his or her county of residence within three business days.
(b)(1)Cases received by the county prior to the 15th day of the month shall be processed for final Medi-Cal eligibility by the county by the end of that month.
(2)Cases received by the county after the 15th day of the month shall be processed for final Medi-Cal eligibility by the 15th day of the following month.
(b)(1)If the referral indicates that an individual is eligible or conditionally eligible for MAGI Medi-Cal, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective according to either of the following timelines, as applicable:
(A)If the referral is received with at least five business days remaining in the month, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective on the first day of the following month.
(B)If the referral is received with less than five business days remaining in the month, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
(2)If the referral requires follow-up to establish Medi-Cal eligibility, the county shall prioritize the referral for processing to ensure the individuals Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
SEC. 4.If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
It is the intent of the Legislature, with the enactment of this act, to establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)Except as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiarys circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c)A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d)Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiarys Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
(1)The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(2)The beneficiary requests that the county determine whether he or she is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e)(1)For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiarys Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiarys file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of his or her immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2)In the case of an annual redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
(A)The eligibility determination and the information it is based on.
(B)That the beneficiary is required to inform the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3)The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4)In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiarys eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f)(1)In the case of an annual eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual renewal form, at least 60 days before the beneficiarys annual redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A)The requirement that he or she provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B)That the beneficiary may respond to the county via the Internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C)That if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
(D)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary via the Internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3)If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate his or her eligibility for Medi-Cal benefits following the provision of timely notice.
(4)If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is not complete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5)(A)The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B)For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g)(1)In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that is prepopulated with the information that the county has obtained and that states the information needed to renew eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means and, if the individual will provide the form by mail or in person, to sign the form. The form shall include a telephone number to call in order to obtain more information. The form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond. Except as provided in paragraph (2), failure to respond prior to the end of this 30-day period shall not impact his or her Medi-Cal eligibility.
(2)If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3)During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h)Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i)If within 90 days of termination of a Medi-Cal beneficiarys eligibility or a change in eligibility status pursuant to this section, the beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined by the county and if the beneficiary is found eligible, or the beneficiarys eligibility status has not changed, whichever applies, the termination shall be rescinded as though the form were submitted in a timely manner.
(j)If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k)The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l)The county shall consider blindness as continuing until the reviewing physician determines that a beneficiarys vision has improved beyond the applicable definition of blindness contained in the plan.
(m)The county shall consider disability as continuing until the review team determines that a beneficiarys disability no longer meets the applicable definition of disability contained in the plan.
(n)In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month eligibility period.
(o)(1)For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs and if the individual is found to be eligible, the county shall, as appropriate, transfer the individuals electronic account to other insurance affordability programs via a secure electronic interface.
(2)If the individual is eligible to enroll in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code, Medi-Cal benefits shall not be terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility. The notice of action shall inform the individual of the date by which he or she must select and enroll in a qualified health plan through the Exchange to avoid being uninsured. If the individual has effectuated his or her enrollment in a qualified health plan through the Exchange before the termination date specified in the notice, Medi-Cal eligibility shall be terminated as of the date of enrollment in the qualified health plan. This paragraph shall only be implemented to the extent that federal financial participation is available.
(p)Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an Internet Web site identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s)For purposes of this section, MAGI-based financial methods means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
(v)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(w)This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 3.Section 15927 is added to the Welfare and Institutions Code, immediately following Section 15926, to read:15927.(a)If an individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) developed under Section 15926, the individuals case information and eligibility determination shall be sent to his or her county of residence within three business days.
(b)(1)Cases received by the county prior to the 15th day of the month shall be processed for final Medi-Cal eligibility by the county by the end of that month.
(2)Cases received by the county after the 15th day of the month shall be processed for final Medi-Cal eligibility by the 15th day of the following month.
(c)An individual described in subdivision (a) who is newly eligible for Medi-Cal shall be enrolled in the Medi-Cal program according to the following procedures:
(1)In a county that provides Medi-Cal services under the two-plan model or the geographic managed care plan model pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), and Article 2.91 (commencing with Section 14089), the individual shall be enrolled in a Medi-Cal managed care plan according to either of the following:
(A)If the qualified health plan the individual was enrolled in through the Exchange is an available Medi-Cal managed care plan in his or her county and that plan has the same or substantially similar provider network, the individual shall be assigned to that plan.
(B)The individual shall be assigned to a plan using the usual Medi-Cal managed care default algorithm.
(2)In a county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5), the individual shall be enrolled into the county organized health system plan on the first date of Medi-Cal coverage and shall be sent the provider directory for the managed care plan.
SEC. 4.If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
It is the intent of the Legislature, with the enactment of this act, to establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)Except as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiarys circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c)A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d)Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiarys Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
(1)The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(2)The beneficiary requests that the county determine whether he or she is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e)(1)For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiarys Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiarys file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of his or her immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2)In the case of an annual redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
(A)The eligibility determination and the information it is based on.
(B)That the beneficiary is required to inform the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3)The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4)In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiarys eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f)(1)In the case of an annual eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual renewal form, at least 60 days before the beneficiarys annual redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A)The requirement that he or she provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B)That the beneficiary may respond to the county via the Internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C)That if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
(D)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary via the Internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3)If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate his or her eligibility for Medi-Cal benefits following the provision of timely notice.
(4)If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is not complete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5)(A)The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B)For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g)(1)In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that is prepopulated with the information that the county has obtained and that states the information needed to renew eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means and, if the individual will provide the form by mail or in person, to sign the form. The form shall include a telephone number to call in order to obtain more information. The form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond. Except as provided in paragraph (2), failure to respond prior to the end of this 30-day period shall not impact his or her Medi-Cal eligibility.
(2)If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3)During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h)Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i)If within 90 days of termination of a Medi-Cal beneficiarys eligibility or a change in eligibility status pursuant to this section, the beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined by the county and if the beneficiary is found eligible, or the beneficiarys eligibility status has not changed, whichever applies, the termination shall be rescinded as though the form were submitted in a timely manner.
(j)If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k)The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l)The county shall consider blindness as continuing until the reviewing physician determines that a beneficiarys vision has improved beyond the applicable definition of blindness contained in the plan.
(m)The county shall consider disability as continuing until the review team determines that a beneficiarys disability no longer meets the applicable definition of disability contained in the plan.
(n)In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month eligibility period.
(o)(1)For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs and if the individual is found to be eligible, the county shall, as appropriate, transfer the individuals electronic account to other insurance affordability programs via a secure electronic interface.
(2)If the individual is eligible to enroll in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code under any insurance affordability program, Code, Medi-Cal benefits shall not be terminated until at least 30 20 days after the county sends the notice of action terminating Medi-Cal eligibility. The notice of action shall inform the individual of the date by which he or she must select and enroll in a qualified health plan through the Exchange to avoid being uninsured. If the individual has effectuated his or her enrollment in a qualified health plan through the Exchange before the termination date specified in the notice, Medi-Cal eligibility shall be terminated as of the date of enrollment in the qualified health plan. This paragraph shall only be implemented to the extent that federal financial participation is available.
(p)Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an Internet Web site identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s)For purposes of this section, MAGI-based financial methods means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
(v)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(w)This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
SEC. 3.Section 15927 is added to the Welfare and Institutions Code, immediately following Section 15926, to read:15927.(a)If an individual enrolled in a qualified health plan through the California Health Benefit Exchange established under Title 22 (commencing with Section 100500) of the Government Code reports a change in circumstances, goes through the renewal process, or is reevaluated for eligibility and there is a change affecting his or her eligibility for any insurance affordability program, the individuals case shall be run through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) developed under Section 15926. If CalHEERS receives information indicating that an individual who has been enrolled in a qualified health plan through the Exchange is newly eligible for Medi-Cal, the individuals case file shall be sent to his or her county of residence within three business days.
(b)(1)If the county of residence receives a case file regarding an individual described in subdivision (a) who is newly eligible for Medi-Cal, the county shall not treat this as a new Medi-Cal application.
(A)Case files
15927.(a)If an individual who has been enrolled in a qualified health plan through the Exchange is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) developed under Section 15926, the individuals case information and eligibility determination shall be sent to his or her county of residence within three business days.
(b)(1)Cases received by the county prior to the 15th day of the month shall be processed for final Medi-Cal eligibility by the county by the end of that month.
(B)Case files
(2)Cases received by the county after the 15th day of the month shall be processed for final Medi-Cal eligibility by the 15th day of the following month.
(2)For individuals described in subdivision (a) who are newly eligible for Medi-Cal, the county shall issue a notice at least 15 days before the individuals enrollment in a qualified health plan through the Exchange ends that advises the individual of all of the following information:
(A)He or she will be enrolled into Medi-Cal.
(B)Instructions on how to select a Medi-Cal managed care health plan.
(C)His or her right to appeal an action related to the individuals eligibility for or enrollment in an insurance affordability program pursuant to Section 100506.1 of the Government Code.
(D)Instructions on how to request continued enrollment in a qualified health benefit plan pending the outcome of his or her appeal of an action related to the individuals eligibility for or enrollment in an insurance affordability program.
(3)If information is needed by the county to verify income, the county shall follow the procedures set forth in subdivisions (f) and (g) of Section 14005.37 to obtain that information.
(c)An individual described in subdivision (a) who is newly eligible for Medi-Cal shall be enrolled in the Medi-Cal program according to the following procedures:
(1)(A)In a county that provides Medi-Cal services under the two-plan model or the geographic managed care plan model pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), and Article 2.91 (commencing with Section 14089), the individual shall be enrolled in a Medi-Cal managed care plan according to either of the following:
(i)
(A)If the qualified health plan the individual was enrolled in through the Exchange is an available Medi-Cal managed care plan in his or her county and that plan has the same or substantially similar provider network, the individual shall be assigned to that plan.
(ii)
(B)The individual shall be assigned to a plan using the usual Medi-Cal managed care default algorithm.
(B)The 15-day notice issued to the individual newly eligible for Medi-Cal shall advise him or her of all of the following information:
(i)The Medi-Cal managed care plan to which he or she will be assigned if the individual does not take any action.
(ii)The individual may choose any available Medi-Cal managed care plan.
(iii)A description of the Medi-Cal managed care plans available in his or her county.
(iv)Instructions on how the individual may change Medi-Cal managed care plans.
(2)In a county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5), the individual shall be enrolled into the county organized health system plan on the first date of Medi-Cal coverage and shall be sent the provider directory for the managed care plan.
SEC. 4.If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
It is the intent of the Legislature to enact legislation that would Legislature, with the enactment of this act, to establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)Except as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiarys circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c)A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d)Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiarys Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only if either of the following occurs:
(A)
(1)The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(B)
(2)The beneficiary requests that the county determine whether he or she is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e)(1)For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiarys Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts shall include information contained in the beneficiarys file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of his or her immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2)In the case of an annual redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of both of the following:
(A)The eligibility determination and the information it is based on.
(B)That the beneficiary is required to inform the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3)The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4)In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiarys eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f)(1)In the case of an annual eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual renewal form, at least 60 days before the beneficiarys annual redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A)The requirement that he or she provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B)That the beneficiary may respond to the county via the Internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C)That if the beneficiary chooses to return the form to the county in person or via mail, the beneficiary shall sign the form in order for it to be considered complete.
(D)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary via the Internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3)If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate his or her eligibility for Medi-Cal benefits following the provision of timely notice.
(4)If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is not complete, the county shall follow the procedures set forth in paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5)(A)The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B)For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g)(1)In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that is prepopulated with the information that the county has obtained and that states the information needed to renew eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the Internet, by telephone, by mail, in person, or through other commonly available electronic means and, if the individual will provide the form by mail or in person, to sign the form. The form shall include a telephone number to call in order to obtain more information. The form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond. Except as provided in paragraph (2), failure to respond prior to the end of this 30-day period shall not impact his or her Medi-Cal eligibility.
(2)If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3)During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h)Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i)If within 90 days of termination of a Medi-Cal beneficiarys eligibility or a change in eligibility status pursuant to this section, the beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined by the county and if the beneficiary is found eligible, or the beneficiarys eligibility status has not changed, whichever applies, the termination shall be rescinded as though the form were submitted in a timely manner.
(j)If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k)The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l)The county shall consider blindness as continuing until the reviewing physician determines that a beneficiarys vision has improved beyond the applicable definition of blindness contained in the plan.
(m)The county shall consider disability as continuing until the review team determines that a beneficiarys disability no longer meets the applicable definition of disability contained in the plan.
(n)In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month eligibility period.
(o)(1)For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs and if the individual is found to be eligible, the county shall, as appropriate, transfer the individuals electronic account to other insurance affordability programs via a secure electronic interface.
(2)If the individual is eligible to enroll in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code under any insurance affordability program, Medi-Cal benefits shall not be terminated until at least 30 days after the county sends the notice of action terminating Medi-Cal eligibility. The notice of action shall inform the individual of the date by which he or she must select and enroll in a qualified health plan through the Exchange to avoid being uninsured. If the individual has effectuated his or her enrollment in a qualified health plan through the Exchange before the termination date specified in the notice, Medi-Cal eligibility shall be terminated as of the date of enrollment in the qualified health plan.
(p)Any renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an Internet Web site identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s)For purposes of this section, MAGI-based financial methods means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31, 2014.
(v)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(w)This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
(x)This section shall become operative on January 1, 2014.
SEC. 3.Section 15927 is added to the Welfare and Institutions Code, immediately following Section 15926, to read:15927.(a)If an individual enrolled in a qualified health plan through the California Health Benefit Exchange established under Title 22 (commencing with Section 100500) of the Government Code reports a change in circumstances, goes through the renewal process, or is reevaluated for eligibility and there is a change affecting his or her eligibility for any insurance affordability program, the individuals case shall be run through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) developed under Section 15926. If CalHEERS receives information indicating that an individual who has been enrolled in a qualified health plan through the Exchange is newly eligible for Medi-Cal, the individuals case file shall be sent to his or her county of residence within three business days.
(b)(1)If the county of residence receives a case file regarding an individual described in subdivision (a) who is newly eligible for Medi-Cal, the county shall not treat this as a new Medi-Cal application.
(A)Case files received by the county prior to the 15th day of the month shall be processed for final Medi-Cal eligibility by the county by the end of that month.
(B)Case files received by the county after the 15th day of the month shall be processed for final Medi-Cal eligibility by the 15th day of the following month.
(2)For individuals described in subdivision (a) who are newly eligible for Medi-Cal, the county shall issue a notice at least 15 days before the individuals enrollment in a qualified health plan through the Exchange ends that advises the individual of all of the following information:
(A)He or she will be enrolled into Medi-Cal.
(B)Instructions on how to select a Medi-Cal managed care health plan.
(C)His or her right to appeal an action related to the individuals eligibility for or enrollment in an insurance affordability program pursuant to Section 100506.1 of the Government Code.
(D)Instructions on how to request continued enrollment in a qualified health benefit plan pending the outcome of his or her appeal of an action related to the individuals eligibility for or enrollment in an insurance affordability program.
(3)If information is needed by the county to verify income, the county shall follow the procedures set forth in subdivisions (f) and (g) of Section 14005.37 to obtain that information.
(c)An individual described in subdivision (a) who is newly eligible for Medi-Cal shall be enrolled in the Medi-Cal program according to the following procedures:
(1)(A)In a county that provides Medi-Cal services under the two-plan model or the geographic managed care plan model pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), and Article 2.91 (commencing with Section 14089), the individual shall be enrolled in a Medi-Cal managed care plan according to either of the following:
(i)If the qualified health plan the individual was enrolled in through the Exchange is an available Medi-Cal managed care plan in his or her county and that plan has the same or substantially similar provider network, the individual shall be assigned to that plan.
(ii)The individual shall be assigned to a plan using the usual Medi-Cal managed care default algorithm.
(B)The 15-day notice issued to the individual newly eligible for Medi-Cal shall advise him or her of all of the following information:
(i)The Medi-Cal managed care plan to which he or she will be assigned if the individual does not take any action.
(ii)The individual may choose any available Medi-Cal managed care plan.
(iii)A description of the Medi-Cal managed care plans available in his or her county.
(iv)Instructions on how the individual may change Medi-Cal managed care plans.
(2)In a county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5), the individual shall be enrolled into the county organized health system plan on the first date of Medi-Cal coverage and shall be sent the provider directory for the managed care plan.
SEC. 4.If the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
It is the intent of the Legislature to enact legislation that would establish procedures to ensure that individuals move between Medi-Cal and the California Health Benefit Exchange without any breaks in coverage as required under subdivision (h) of Section 15926 of the Welfare and Institutions Code.
|
Date
|
Status
|
|---|---|
| Jun 6, 2016 | In Senate. Read first time. To Com. on RLS. for assignment. |
| Sep 9, 2016 | Enrolled and presented to the Governor at 2:30 p.m. |
| Aug 31, 2016 | Senate amendments concurred in. To Engrossing and Enrolling. |
| Aug 30, 2016 | In Assembly. Concurrence in Senate amendments pending. |
| Aug 25, 2016 | Read third time. Passed. Ordered to the Assembly. (Ayes 39. Noes 0. Page 5417.). |
| Aug 25, 2016 | Read third time. Passed. Ordered to the Assembly. |
| Aug 22, 2016 | Read second time. Ordered to third reading. |
| Aug 19, 2016 | Read third time and amended. Ordered to second reading. |
| Aug 15, 2016 | Read second time. Ordered to third reading. |
| Aug 11, 2016 | From committee: Do pass. (Ayes 7. Noes 0.) (August 11). |
| Aug 8, 2016 | Referred to APPR. suspense file. |
| Aug 1, 2016 | In committee: Hearing postponed by committee. |
| Jun 27, 2016 | Read second time and amended. Re-referred to Com. on APPR. |
| Jun 23, 2016 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 9. Noes 0.) (June 22). |
| Jun 9, 2016 | Referred to Com. on HEALTH. |
| Feb 17, 2016 | Read first time. To print. |
| Jun 2, 2016 | Read third time. Passed. Ordered to the Senate. (Ayes 80. Noes 0. Page 5172.) |
| Jun 2, 2016 | Read third time. Passed. Ordered to the Senate. |
| Jun 2, 2016 | Read second time. Ordered to third reading. |
| Jun 2, 2016 | Assembly Rule 63 suspended. (Page 5166.) |
| Jun 2, 2016 | Assembly Rule 63 suspended. (Ayes 80. Noes 0.) |
| Jun 2, 2016 | Assembly Rule 63 suspended. |
| Jun 1, 2016 | Read second time and amended. Ordered returned to second reading. |
| May 31, 2016 | From committee: Amend, and do pass as amended. (Ayes 14. Noes 0.) (May 27). |
| Apr 20, 2016 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Apr 6, 2016 | From committee: Do pass and re-refer to Com. on APPR. (Ayes 18. Noes 0.) (April 5). Re-referred to Com. on APPR. |
| Mar 28, 2016 | Re-referred to Com. on HEALTH. |
| Mar 18, 2016 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 17, 2016 | Referred to Com. on HEALTH. |
| Feb 18, 2016 | From printer. May be heard in committee March 19. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Aug 31, 2016 | AB 2077 BURKE Concurrence in Senate Amendments | Assembly Floor |
Passed |
|
| Aug 25, 2016 | Assembly 3rd Reading AB2077 Burke By Hernandez | Senate Floor |
Passed |
|
| Aug 11, 2016 | Do pass | Senate Standing Committee on Appropriations |
Passed |
|
| Aug 8, 2016 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Jun 22, 2016 | Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
|
| Jun 2, 2016 | AB 2077 BURKE Assembly Third Reading | Assembly Floor |
Passed |
|
| May 27, 2016 | Do pass as amended. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 5, 2016 | Do pass and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Advancing Justice California | ** Support | Jun 2, 2016 |
| American Cancer Society Cancer Action Network Inc. | ** Support | Aug 25, 2016 |
| Asian Americans Advancing Justice | ** Support | Aug 25, 2016 |
| Asian Law Alliance | ** Support | Aug 25, 2016 |
| California Black Health Network | ** Support | Aug 25, 2016 |
| California Coverage and Health Initiatives | * Support | Jun 22, 2016 |
| California Immigrant Policy Center | ** Support | Jun 22, 2016 |
| California Pan-Ethnic Health Network | ** Support | Aug 25, 2016 |
| California School Employees Association AFL-CIO | ** Support | Aug 25, 2016 |
| Children Now | ** Support | Aug 25, 2016 |
| Children'S Defense Fund | ** Support | Jun 22, 2016 |
| Congress of California Seniors | ** Support | Aug 25, 2016 |
| Consumers Union | ** Support | Aug 25, 2016 |
| Department Of Finance | ** Against | Aug 25, 2016 |
| Health Access California | ** Support | Aug 25, 2016 |
| Justice in Aging | ** Support | Aug 25, 2016 |
| Legal Aid Society of Orange County | ** Support | Jun 22, 2016 |
| Legal Aid Society of San Mateo County | ** Support | Aug 25, 2016 |
| Legal Services of Northern California | ** Support | Aug 25, 2016 |
| National Association Of Social Workers, California Chapter | * Support | Jun 22, 2016 |
| National Health Law Program | ** Support | Aug 25, 2016 |
| Private Essential Access Community Hospitals | ** Support | Aug 25, 2016 |
| Project Inform | ** Support | Aug 25, 2016 |
| The Children's Partnership | ** Support | Aug 25, 2016 |
| United Ways Of California | * Support | Jun 22, 2016 |
| Western Center On Law And Poverty Inc. | ** Support | Aug 25, 2016 |
| Women's Health Specialists of California | * Support | Jun 22, 2016 |
GOVERNOR'S VETO
GV Bill Id:AB 2077
Author:(Burke and Bonilla)
As Enrolled Ver:September 9, 2016
2/3 vote
ASSEMBLY: | 80-0 | (June 2, 2016) | SENATE: | 39-0 | (August 25, 2016) |
ASSEMBLY: | 79-0 | (August 31, 2016) |
Original Committee Reference: HEALTH
SUMMARY: Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action (NOA) terminating Medi-Cal eligibility if the individual is eligible to enroll in a qualified health plan (QHP) through Covered California, to the extent federal financial participation is available. Establishes application processing timelines for counties for individuals who were enrolled in California's Health Benefit Exchange (also known as Covered California) and who are determined newly eligible for Medi-Cal through the application processing system known as the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS).
The Senate amendments:
- Delete language specifying that individuals who effectuated enrollment in a QHP prior to the termination date specified in the NOA, then Medi-Cal eligibility will be terminated as of the QHP enrollment date.
- Delete language specifying that for individuals enrolled in a QHP and newly eligible for Medi-Cal, cases received by the county prior to the 15th day of the month be processed for final Medi-Cal eligibility by the end of the month and cases received by the county after the 15th of the month be processed for final Medi-Cal eligibility by the 15th day of the following month.
- Add language specifying that for referrals of a Modified Adjusted Gross Income Medi-Cal eligible individual, the county is required to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective according to either of the following timelines, as applicable:
- Requires the county to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective on the first day of the following month if the referral is received with at least five business days remaining in the month; and,
- Requires the county to prioritize the referral for processing to ensure the individual's eligibility is effective no later than the first day of the second month following receipt of the referral if the referral is received with less than five business days remaining in the month.
- Add language requiring the county to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral if the referral requires follow-up to establish Medi-Cal eligibility.
- Delete the Medi-Cal enrollment procedure requirements for newly eligible Medi-Cal individuals, specifically:
- For individuals previously enrolled through Covered California and the QHP is available as a Medi-Cal managed care plan in the same county and the health plan has the same or substantially similar provider network;
- For individuals assigned to a health plan using the usual Medi-Cal managed care default algorithm; and,
- For individuals enrolled into the county organized health system plan.
FISCAL EFFECT: According to the Senate Appropriations Committee:
- One-time costs in the hundreds of thousands, for the Department of Health Care Services (DHCS) to change internal processes, revise regulations, and seek any necessary federal approvals (General Fund and federal funds).
- One-time costs in the hundreds of thousands to make system changes to several information technology systems used to determine eligibility for Medi-Cal and Covered California coverage and to manage Medi-Cal enrollment (General Fund and federal funds). In order to facilitate the requirements of this bill, system changes will be needed to CalHEERS (the system used to process applications for Medi-Cal and Covered California coverage) and MEDS (the system used to managed Medi-Cal enrollment). It is possible that those costs would be eligible for enhanced federal matching rate of 90%.
- One-time costs of $2.5 million to make system changes to the SAWS (the systems used by counties to determine eligibility for Medi-Cal) (General Fund and federal funds).
- Ongoing costs of $3 million to $5 million per year from extended Medi-Cal eligibility during transitions to Covered California coverage (General Fund and federal funds). Under current practice, when an individual loses eligibility for Medi-Cal (generally because of an increase in income), the individual is given 10 days notice before coverage is terminated. This bill would require individuals to be given 20 days notice before coverage is terminated. Medi-Cal coverage would be terminated before 20 days, if the individual enrolls in coverage through Covered California. Because Medi-Cal enrollment is granted monthly, extending the transition period from 10 to 20 days will result in roughly a third of transitioning individuals receiving an additional month of coverage. According to data published by DHCS, there are 5,000-6,000 individuals per month who transition from Covered California to Medi-Cal. Staff assumes that a roughly similar number of individuals transition from Medi-Cal to Covered California each month.
- Ongoing costs, potentially in the low millions due to increased enrollment in Medi-Cal of individuals transitioning from Covered California coverage to Medi-Cal (General Fund and federal funds). This bill would impose new deadlines on counties to determine Medi-Cal eligibility for individuals who have lost their Covered California coverage. By imposing such deadlines, this bill may result in earlier Medi-Cal enrollment. If 10% of individuals in that situation become eligible for Medi-Cal for one extra month under this bill, the annual cost would be about $3 million.
COMMENTS: According to the author, this bill eases the transition between plans for those moving from Covered California plans to Medi-Cal and vice versa. For individuals moving from Medi-Cal to Covered California, they will have 20 days before their Medi-Cal benefits expire. Those moving from Covered California to Medi-Cal will also have additional time to select a plan, and receive guidance on how to select a plan. By providing a coverage bridge for Californians transitioning between plans, we can make sure that no one falls through a coverage gap.
DHCS concerns. The problems with transitions between Covered California and Medi-Cal has been discussed with DHCS and Covered California, and the improved notices regarding the need to promptly pick a plan for new Covered California enrollees are currently scheduled to take effect in the CalHEERS release in September 2016. With regard to the 20 day NOA (instead of the current 10 day NOA), DHCS indicates this change would treat individuals in a transition differently than new applicants for Medi-Cal coverage. This change would require changes to DHCS' existing infrastructure for a subset of individuals, and is counter to DHCS' desire to treat individuals the same. If the NOA timeframe were changed to 20 days for all Medi-Cal beneficiaries, DHCS indicates this would have an impact on Medi-Cal costs as more individuals would remain on the program an additional month.
I am returning Assembly Bill 2077 without my signature.
This bill allows people to stay on Medi-Cal longer in order to sign up for Covered California. The bill also requires counties to prioritize applications from new enrollees into Medi-Cal from Covered California.
The ability to maintain coverage while transitioning between Medi-Cal and Covered California may indeed be a daunting task. I am not comfortable, however, with the approach this bill proposes by giving more time on Medi-Cal to some, and preferential enrollment to others.
The Department of Health Care Services and Covered California are currently working on improvements to the eligibility and enrollment systems to give people the timely information they need to ease the transition from one program to the other.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0005077
CONCURRENCE IN SENATE AMENDMENTS
CSA1 Bill Id:AB 2077
Author:(Burke and Bonilla)
As Amended Ver:August 19, 2016
Majority vote
ASSEMBLY: | 80-0 | (June 2, 2016) | SENATE: | 39-0 | (August 25, 2016) |
Original Committee Reference: HEALTH
SUMMARY: Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action (NOA) terminating Medi-Cal eligibility if the individual is eligible to enroll in a qualified health plan (QHP) through Covered California, to the extent federal financial participation is available. Establishes application processing timelines for counties for individuals who were enrolled in California's Health Benefit Exchange (also known as Covered California) and who are determined newly eligible for Medi-Cal through the application processing system known as the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS).
The Senate amendments:
- Delete language specifying that individuals who effectuated enrollment in a QHP prior to the termination date specified in the NOA, then Medi-Cal eligibility will be terminated as of the QHP enrollment date.
- Delete language specifying that for individuals enrolled in a QHP and newly eligible for Medi-Cal, cases received by the county prior to the 15th day of the month be processed for final Medi-Cal eligibility by the end of the month and cases received by the county after the 15th of the month be processed for final Medi-Cal eligibility by the 15th day of the following month.
- Add language specifying that for referrals of a Modified Adjusted Gross Income Medi-Cal eligible individual, the county is required to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective according to either of the following timelines, as applicable:
- Requires the county to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective on the first day of the following month if the referral is received with at least five business days remaining in the month; and,
- Requires the county to prioritize the referral for processing to ensure the individual's eligibility is effective no later than the first day of the second month following receipt of the referral if the referral is received with less than five business days remaining in the month.
- Add language requiring the county to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral if the referral requires follow-up to establish Medi-Cal eligibility.
- Delete the Medi-Cal enrollment procedure requirements for newly eligible Medi-Cal individuals, specifically:
- For individuals previously enrolled through Covered California and the QHP is available as a Medi-Cal managed care plan in the same county and the health plan has the same or substantially similar provider network;
- For individuals assigned to a health plan using the usual Medi-Cal managed care default algorithm; and,
- For individuals enrolled into the county organized health system plan.
FISCAL EFFECT: According to the Senate Appropriations Committee:
- One-time costs in the hundreds of thousands, for the Department of Health Care Services (DHCS) to change internal processes, revise regulations, and seek any necessary federal approvals (General Fund and federal funds).
- One-time costs in the hundreds of thousands to make system changes to several information technology systems used to determine eligibility for Medi-Cal and Covered California coverage and to manage Medi-Cal enrollment (General Fund and federal funds). In order to facilitate the requirements of this bill, system changes will be needed to CalHEERS (the system used to process applications for Medi-Cal and Covered California coverage) and MEDS (the system used to managed Medi-Cal enrollment). It is possible that those costs would be eligible for enhanced federal matching rate of 90%.
- One-time costs of $2.5 million to make system changes to the SAWS (the systems used by counties to determine eligibility for Medi-Cal) (General Fund and federal funds).
- Ongoing costs of $3 million to $5 million per year from extended Medi-Cal eligibility during transitions to Covered California coverage (General Fund and federal funds). Under current practice, when an individual loses eligibility for Medi-Cal (generally because of an increase in income), the individual is given 10 days notice before coverage is terminated. This bill would require individuals to be given 20 days notice before coverage is terminated. Medi-Cal coverage would be terminated before 20 days, if the individual enrolls in coverage through Covered California. Because Medi-Cal enrollment is granted monthly, extending the transition period from 10 to 20 days will result in roughly a third of transitioning individuals receiving an additional month of coverage. According to data published by DHCS, there are 5,000-6,000 individuals per month who transition from Covered California to Medi-Cal. Staff assumes that a roughly similar number of individuals transition from Medi-Cal to Covered California each month.
- Ongoing costs, potentially in the low millions due to increased enrollment in Medi-Cal of individuals transitioning from Covered California coverage to Medi-Cal (General Fund and federal funds). This bill would impose new deadlines on counties to determine Medi-Cal eligibility for individuals who have lost their Covered California coverage. By imposing such deadlines, this bill may result in earlier Medi-Cal enrollment. If 10% of individuals in that situation become eligible for Medi-Cal for one extra month under this bill, the annual cost would be about $3 million.
COMMENTS: According to the author, this bill eases the transition between plans for those moving from Covered California plans to Medi-Cal and vice versa. For individuals moving from Medi-Cal to Covered California, they will have 20 days before their Medi-Cal benefits expire. Those moving from Covered California to Medi-Cal will also have additional time to select a plan, and receive guidance on how to select a plan. By providing a coverage bridge for Californians transitioning between plans, we can make sure that no one falls through a coverage gap.
DHCS concerns. The problems with transitions between Covered California and Medi-Cal has been discussed with DHCS and Covered California, and the improved notices regarding the need to promptly pick a plan for new Covered California enrollees are currently scheduled to take effect in the CalHEERS release in September 2016. With regard to the 20 day NOA (instead of the current 10 day NOA), DHCS indicates this change would treat individuals in a transition differently than new applicants for Medi-Cal coverage. This change would require changes to DHCS' existing infrastructure for a subset of individuals, and is counter to DHCS' desire to treat individuals the same. If the NOA timeframe were changed to 20 days for all Medi-Cal beneficiaries, DHCS indicates this would have an impact on Medi-Cal costs as more individuals would remain on the program an additional month.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0004758
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB |
THIRD READING
Bill No: AB 2077
:
SENATE HEALTH COMMITTEE: 9-0, 6/22/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen
ASSEMBLY FLOOR: 80-0, 6/2/16 - See last page for vote
SOURCE: Western Center on Law and Poverty
DIGEST: This bill prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility if the individual is eligible to enroll in a qualified health plan through Covered California, to the extent federal financial participation is available. This bill requires counties to prioritize processing applications for individuals who were enrolled in Covered California and who are determined newly eligible for Medi-Cal through the application processing system known as the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS).
Senate Floor Amendments of 8/19/16 provide different county application processing timeframes when people move from Covered California to Medi-Cal who have applied through CalHEERS, and remove a requirement for counties to terminate Medi-Cal coverage early if the individual is already enrolled in a Covered California plan.
Existing law:
- Requires, during the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for an insurance affordability program (such as Medi-Cal or Covered California) to ensure that an eligible applicant and recipient of insurance affordability programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage.
- Requires counties, for individuals determined ineligible for Medi-Cal by a county following the redetermination procedures, eligibility to be determined for other insurance affordability programs. Requires the county, if the individual is found to be eligible, to transfer the individual’s electronic account to other insurance affordability programs via a secure electronic interface.
- Requires county social service departments to notify beneficiaries in writing of their Medi-Cal-only eligibility or ineligibility, and of any changes made in their eligibility status or share of cost. These notifications are called a “Notice of Action (NOA).” NOAs inform Medi-Cal beneficiaries of:
- Any approval, denial or discontinuance of eligibility;
- A change in the beneficiary’s share of cost;
- The reason an action is being taken and the law or regulation that requires the action (if the action is a denial, discontinuance or increase in share of cost); and,
- The right to request a state hearing.
This bill:
- Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the NOA terminating Medi-Cal eligibility if the individual is eligible to enroll in a quality health plan (QHP) through Covered California.
- Requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through Covered California to avoid being uninsured.
- Implements 1) and 2) above only to the extent that federal financial participation is available.
- Requires, if an individual who has been enrolled in a QHP through Covered California is determined newly eligible for Medi-Cal through the CalHEERS, the individual’s case information and eligibility determination to be sent to his or her county of residence within three business days. (CalHEERS is the on-line application system administered by Covered California and Department of Health Care Services (DHCS).)
- Requires counties, for an individual who was previously enrolled in coverage through Covered California, who enrolled through CalHEERS, and is determined newly eligible for Medi-Cal, if a referral from indicates that an individual is eligible or conditionally eligible for MAGI Medi-Cal based on Modified Adjusted Gross Income (MAGI), to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective according to either of the following timelines, as applicable:
- Requires the county, if the referral is received with at least five business days remaining in the month, the county to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective on the first day of the following month.
- Requires the county, if the referral is received with less than five business days remaining in the month, to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
- Requires counties, if the referral requires follow-up to establish Medi-Cal eligibility, to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective no later than the first day of the second month following receipt of the referral.
- States legislative intent to establish procedures to ensure that individuals move between Medi-Cal and Covered California without any breaks in coverage as required under a specified provision of existing law.
Comments
- Author’s statement. According to the author, this bill eases the transition between plans for those moving from Covered California plans to Medi-Cal and vice versa. For individuals moving from Medi-Cal to Covered California, they will have 20 days before their Medi-Cal benefits expire. Those moving from Covered California to Medi-Cal will also have additional time to select a plan, and receive guidance on how to select a plan. By providing a coverage bridge for Californians transitioning between plans, we can make sure that no one falls through a coverage gap.
- Transitions between coverage programs. Eligibility for Medi-Cal and Covered California Advanced Premium Tax Credit and cost-sharing subsidies are based in part on income. Most adults can qualify for Medi-Cal with incomes up to 138% of the Federal Poverty Level (FPL) ($33,534 a year for a family of four in 2016) and children can qualify with incomes up to 266% FPL ($64,638 for a family of four in 2016). People whose incomes are higher than these thresholds can get health coverage through Covered California and can qualify for subsidies with incomes up to 400% FPL ($97,200 for a family of four in 2016). When an individual experiences a change in income, they may move between the two programs. These transitions can occur during the course of the year as a result of a change in income, due to a change in the FPL, when an individual has a change in family size, or at annual eligibility redetermination. When an individual’s income increases or decreases, they can move from Medi-Cal to Covered California or vice versa.
DHCS indicates (based on prior years’ data), approximately 80,000 to 100,000 cases transitioned from Covered California to Medi-Cal in the January timeframe, due to Covered California’s annual renewal period (which ends December 31st of each year). An additional 5,000 to 10,000 cases transition from Covered California to Medi-Cal on a monthly basis throughout the remainder of the year, due to reported changes in circumstances. Based on DHCS’ data, on average 2,800 – 5,000 Medi-Cal cases transition each month to Covered California.
Existing law already requires transitions between the programs without a break in coverage. This bill establishes more specific provisions on how transitions from Medi-Cal to Covered California (and vice versa) will work, as follows:
- Covered California to Medi-Cal. When an individual moves from coverage in Covered California to Medi-Cal through CalHEERS, this bill requires that case information to be sent to their county of residence within three business days (Covered California indicates this information is transmitted immediately under current practice).
Under existing law, counties receiving these cases have 45 days to make a Medi-Cal eligibility determination for most cases. Under this bill, shorter timeframes would apply for these individuals if the referral is received with at least five business days remaining in the month. For these individuals, the county is required to prioritize the referral for processing to ensure the individual's Medi-Cal eligibility is effective on the first day of the following month. The purpose of this expedited timeframe is so that individuals are not required to incur premiums and cost-sharing for Covered California coverage when they are Medi-Cal eligible.
- Medi-Cal to Covered California. When an individual moves from Covered California to Medi-Cal, this bill would prohibit Medi-Cal benefits from being terminated until at least 20 days after the county sends a NOA terminating Medi-Cal eligibility. Under current law, NOAs are sent 10 days prior to Medi-Cal eligibility being discontinued.
There are several reasons for this longer timeframe. Because Medi-Cal coverage is a monthly basis, a notice mailed mid-month would not meet the 20-day notice, so Medi-Cal coverage would continue through the following month. For example, if Medi-Cal coverage was discovered to be discontinued on March 12, the 20 day notice requirement would mean the coverage discontinuance would not take effect until May 1, (because the 20 day notice would fall after the end of March). Under a 10 day NOA requirement, the individual’s coverage would terminate April 1. In addition, the 20-day notice provides an individual a longer time period to select a QHP in Covered California. To address DHCS’ concern that this would result in a state-only Medi-Cal cost for an additional month of Medi-Cal coverage, this bill contains language making this provision contingent upon FFP being available.
In addition, this bill requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through the Exchange to avoid being uninsured. This provision addresses an issue with the existing notices, which do not notify individuals of the need for prompt action if they do not pick a QHP so as to avoid a gap between when their Medi-Cal coverage ends and their Covered California coverage begins. The notice fixes are currently scheduled for implementation in September 2016.
FISCAL EFFECT: Appropriation: Fiscal Com.: Local:
According to the Senate Appropriations Committee:
- One-time costs in the hundreds of thousands, for DHCS to change internal processes, revise regulations, and seek any necessary federal approvals (General Fund and federal funds).
- One-time costs in the hundreds of thousands to make system changes to several information technology systems used to determine eligibility for Medi-Cal and Covered California coverage and to manage Medi-Cal enrollment (General Fund and federal funds). In order to facilitate the requirements of the bill, system changes will be needed to CalHEERS (the system used to process applications for Medi-Cal and Covered California coverage) and MEDS (the system used to managed Medi-Cal enrollment). It is possible that those costs would be eligible for enhanced federal matching rate of 90%.
- One-time costs of $2.5 million to make system changes to the SAWS (the systems used by counties to determine eligibility for Medi-Cal) (General Fund and federal funds).
- Ongoing costs of $3 million to $5 million per year from extended Medi-Cal eligibility during transitions to Covered California coverage (General Fund and federal funds). Under current practice, when an individual loses eligibility for Medi-Cal (generally because of an increase in income), the individual is given 10-day notice before coverage is terminated. This bill requires individuals to be given 20 days’ notice before coverage is terminated. Medi-Cal coverage would be terminated before 20 days, if the individual enrolls in coverage through Covered California. Because Medi-Cal enrollment is granted monthly, extending the transition period from 10 to 20 days will result in roughly a third of transitioning individuals receiving an additional month of coverage. According to data published by DHCS, there are 5,000-6,000 individuals per month who transition from Covered California to Medi-Cal. Staff assumes that a roughly similar number of individuals transition from Medi-Cal to Covered California each month.
- Ongoing costs, potentially in the low millions due to increased enrollment in Medi-Cal of individuals transitioning from Covered California coverage to Medi-Cal (General Fund and federal funds). The bill imposes new deadlines on counties to determine Medi-Cal eligibility for individuals who have lost their Covered California coverage. By imposing such deadlines, the bill may result in earlier Medi-Cal enrollment. If 10% of individuals in that situation become eligible for Medi-Cal for one extra month under the bill, the annual cost would be about $3 million.
Western Center on Law and Poverty (source)
American Cancer Society Cancer Action Network
Asian Americans Advancing Justice
Asian Law Alliance
California Black Health Network
California Pan-Ethnic Health Network
California School Employees Association AFL-CIO
Central California Legal Services, Inc.
Children Now
Coalition of California Welfare Rights Organizations, Inc.
Congress of California Seniors
Consumers Union
Health Access California
Justice in Aging
Legal Aid Society of San Mateo County
Legal Services of Northern California
National Health Law Program
Private Essential Access Community Hospitals
Project Inform
The Children’s Defense Fund
The Children’s Partnership
OPPOSITION: (Verified 8/18/16)
Department of Finance
ARGUMENTS IN SUPPORT: This bill is sponsored by Western Center on Law and Poverty (WCLP) to put in place policies and procedures to allow people moving between Medi-Cal and Covered California to do so without being uninsured. WCLP writes that many people moving between programs are ending up without health coverage for one to several months despite an existing law provision that requires that individuals be able to move between programs without any breaks in coverage. During gaps in coverage, individuals cannot get the care they need, or they have to pay for care out-of-pocket, which many cannot afford. WCLP argues that when people move from Covered California to Medi-Cal, the state is planning to change its policy of “presumptive eligibility” which enrolls them in Medi-Cal quickly. WCLP states the effect of this change which will be that people will have to say on Covered California while the county makes a final Medi-Cal eligibility determination. WCLP states this forces the person to pay premiums and cost-sharing as if they had higher income when Medi-Cal coverage is free. For individuals moving from Covered Coverage to Medi-Cal, WCLP writes this bill ensures their case is sent to the county right away and is promptly determined. Finally, WCLP writes that this bill also ensures that individuals moving from Medi-Cal to Covered California are being told they most choose a Covered California plan to avoid a break in coverage, and will allow consumers more time to choose and enroll in a Covered California plan.
ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes because it creates additional General Fund costs for DHCS and the Department of Social Services. In addition, DOF states this bill is unnecessary and premature as DHCS and Covered California are already taking steps to address the concerns raised in this bill by planning for the implementation of CalHEERS functionality to address this issue. DOF states that DHCS and the Covered California are already undertaking efforts to improve the transition of beneficiaries between Medi-Cal and QHP coverage, and CalHEERS functionality is scheduled to be implemented in October of 2016 to enhance automation processes for insurance affordability programs transitions.
ASSEMBLY FLOOR: 80-0, 6/2/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon
8/22/16 23:01:08
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Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB |
THIRD READING
Bill No: AB 2077
:
SENATE HEALTH COMMITTEE: 9-0, 6/22/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen
ASSEMBLY FLOOR: 80-0, 6/2/16 - See last page for vote
SOURCE: Western Center on Law and Poverty
DIGEST: This bill prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility if the individual is eligible to enroll in a qualified health plan through Covered California, to the extent federal financial participation is available. This bill establishes application processing timelines for counties for individuals who were enrolled in Covered California and who are determined newly eligible for Medi-Cal through the application processing system known as the California Healthcare Eligibility, Enrollment and Retention System.
Existing law:
- Requires, during the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for an insurance affordability program (such as Medi-Cal or Covered California) to ensure that an eligible applicant and recipient of insurance affordability programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage.
- Requires counties, for individuals determined ineligible for Medi-Cal by a county following the redetermination procedures, eligibility to be determined for other insurance affordability programs. Requires the county, if the individual is found to be eligible, to transfer the individual’s electronic account to other insurance affordability programs via a secure electronic interface.
- Requires county social service departments to notify beneficiaries in writing of their Medi-Cal-only eligibility or ineligibility, and of any changes made in their eligibility status or share of cost. These notifications are called a “Notice of Action (NOA).” NOAs inform Medi-Cal beneficiaries of:
- Any approval, denial or discontinuance of eligibility;
- A change in the beneficiary’s share of cost;
- The reason an action is being taken and the law or regulation that requires the action (if the action is a denial, discontinuance or increase in share of cost); and,
- The right to request a state hearing.
This bill:
- Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the NOA terminating Medi-Cal eligibility if the individual is eligible to enroll in a quality health plan (QHP) through Covered California.
- Requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through the Exchange to avoid being uninsured.
- Requires Medi-Cal eligibility to be terminated as of the date of enrollment in the QHP if the individual has effectuated his or her enrollment in a QHP through Covered California before the termination date specified in the notice.
- Implements 1) through 3) above only to the extent that federal financial participation is available.
- Requires, if an individual who has been enrolled in a QHP through Covered California is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS), the individual’s case information and eligibility determination to be sent to his or her county of residence within three business days. (CalHEERS is the on-line application system administered by Covered California and Department of Health Care Services (DHCS).)
- Requires cases received by the county prior to the 15th day of the month to be processed for final Medi-Cal eligibility by the county by the end of that month.
- Requires cases received by the county after the 15th day of the month to be processed for final Medi-Cal eligibility by the 15th day of the following month.
- States legislative intent to establish procedures to ensure that individuals move between Medi-Cal and Covered California without any breaks in coverage as required under a specified provision of existing law.
Comments
- Author’s statement. According to the author, this bill eases the transition between plans for those moving from Covered California plans to Medi-Cal and vice versa. For individuals moving from Medi-Cal to Covered California, they will have 20 days before their Medi-Cal benefits expire. Those moving from Covered California to Medi-Cal will also have additional time to select a plan, and receive guidance on how to select a plan. By providing a coverage bridge for Californians transitioning between plans, we can make sure that no one falls through a coverage gap.
- Transitions between coverage programs. Eligibility for Medi-Cal and Covered California Advanced Premium Tax Credit and cost-sharing subsidies are based in part on income. Most adults can qualify for Medi-Cal with incomes up to 138% of the Federal Poverty Level (FPL) ($33,534 a year for a family of four in 2016) and children can qualify with incomes up to 266% FPL ($64,638 for a family of four in 2016). People whose incomes are higher than these thresholds can get health coverage through Covered California and can qualify for subsidies with incomes up to 400% FPL ($97,200 for a family of four in 2016). When an individual experiences a change in income, they may move between the two programs. These transitions can occur during the course of the year as a result of a change in income, due to a change in the FPL, when an individual has a change in family size, or at annual eligibility redetermination. When an individual’s income increases or decreases, they can move from Medi-Cal to Covered California or vice versa.
DHCS indicates (based on prior years’ data), approximately 80,000 to 100,000 cases transitioned from Covered California to Medi-Cal in the January timeframe, due to Covered California’s annual renewal period (which ends December 31st of each year). An additional 5,000 to 10,000 cases transition from Covered California to Medi-Cal on a monthly basis throughout the remainder of the year, due to reported changes in circumstances. Based on DHCS’ data, on average 2,800 – 5,000 Medi-Cal cases transition each month to Covered California.
Existing law already requires transitions between the programs without a break in coverage. This bill establishes more specific provisions on how transitions from Medi-Cal to Covered California (and vice versa) will work, as follows:
- Covered California to Medi-Cal. When an individual moves from coverage in Covered California to Medi-Cal through CalHEERS, this bill requires that case information to be sent to their county of residence within three business days (Covered California indicates this information is transmitted immediately under current practice).
Under existing law, counties receiving these cases have 45 days to make a Medi-Cal eligibility determination for most cases. Under this bill, shorter timeframes would apply for these individuals. Cases received by the county prior to the 15th day of the month would have to be processed for final Medi-Cal eligibility by the county by the end of that month. Cases received after the 15th day of the month would have to be processed for final Medi-Cal eligibility by the 15th day of the following month. The purpose of these shorter timeframes is so that individuals are not required to incur premiums and cost-sharing for Covered California coverage when they are Medi-Cal eligible.
- Medi-Cal to Covered California. When an individual moves from Covered California to Medi-Cal, this bill would prohibit Medi-Cal benefits from being terminated until at least 20 days after the county sends a NOA terminating Medi-Cal eligibility. Under current law, NOAs are sent 10 days prior to Medi-Cal eligibility being discontinued. In addition, this bill requirse Medi-Cal eligibility to be terminated as of the date of enrollment in the QHP in Covered California if the individual has effectuated his or her enrollment in a QHP through Covered California before the termination date contained in the notice.
There are several reasons for this longer timeframe. Because Medi-Cal coverage is a monthly basis, a notice mailed mid-month would not meet the 20-day notice, so Medi-Cal coverage would continue through the following month. For example, if Medi-Cal coverage was discovered to be discontinued on March 12, the 20 day notice requirement would mean the coverage discontinuance would not take effect until May 1, (because the 20 day notice would fall after the end of March). Under a 10 day NOA requirement, the individual’s coverage would terminate April 1. In addition, the 20-day notice provides an individual a longer time period to select a QHP in Covered California. To address DHCS’ concern that this would result in a state-only Medi-Cal cost for an additional month of Medi-Cal coverage, this bill contains language making this provision contingent upon FFP being available.
In addition, this bill requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through the Exchange to avoid being uninsured. This provision addresses an issue with the existing notices, which do not notify individuals of the need for prompt action if they do not pick a QHP so as to avoid a gap between when their Medi-Cal coverage ends and their Covered California coverage begins. The notice fixes are currently scheduled for implementation in September 2016.
FISCAL EFFECT: Appropriation: Fiscal Com.: Local:
According to the Senate Appropriations Committee:
- One-time costs in the hundreds of thousands, for DHCS to change internal processes, revise regulations, and seek any necessary federal approvals (General Fund and federal funds).
- One-time costs in the hundreds of thousands to make system changes to several information technology systems used to determine eligibility for Medi-Cal and Covered California coverage and to manage Medi-Cal enrollment (General Fund and federal funds). In order to facilitate the requirements of the bill, system changes will be needed to CalHEERS (the system used to process applications for Medi-Cal and Covered California coverage) and MEDS (the system used to managed Medi-Cal enrollment). It is possible that those costs would be eligible for enhanced federal matching rate of 90%.
- One-time costs of $2.5 million to make system changes to the SAWS (the systems used by counties to determine eligibility for Medi-Cal) (General Fund and federal funds).
- Ongoing costs of $3 million to $5 million per year from extended Medi-Cal eligibility during transitions to Covered California coverage (General Fund and federal funds). Under current practice, when an individual loses eligibility for Medi-Cal (generally because of an increase in income), the individual is given 10-day notice before coverage is terminated. This bill requires individuals to be given 20 days’ notice before coverage is terminated. Medi-Cal coverage would be terminated before 20 days, if the individual enrolls in coverage through Covered California. Because Medi-Cal enrollment is granted monthly, extending the transition period from 10 to 20 days will result in roughly a third of transitioning individuals receiving an additional month of coverage. According to data published by DHCS, there are 5,000-6,000 individuals per month who transition from Covered California to Medi-Cal. Staff assumes that a roughly similar number of individuals transition from Medi-Cal to Covered California each month.
- Ongoing costs, potentially in the low millions due to increased enrollment in Medi-Cal of individuals transitioning from Covered California coverage to Medi-Cal (General Fund and federal funds). The bill imposes new deadlines on counties to determine Medi-Cal eligibility for individuals who have lost their Covered California coverage. By imposing such deadlines, the bill may result in earlier Medi-Cal enrollment. If 10% of individuals in that situation become eligible for Medi-Cal for one extra month under the bill, the annual cost would be about $3 million.
Western Center on Law and Poverty (source)
American Cancer Society Cancer Action Network
Asian Americans Advancing Justice
Asian Law Alliance
California Black Health Network
California Pan-Ethnic Health Network
California School Employees Association AFL-CIO
Central California Legal Services, Inc.
Children Now
Coalition of California Welfare Rights Organizations, Inc.
Congress of California Seniors
Consumers Union
The Children’s Defense Fund
The Children’s Partnership
Health Access California
Justice in Aging
Legal Aid Society of San Mateo County
Legal Services of Northern California
National Health Law Program
Private Essential Access Community Hospitals
Project Inform
OPPOSITION: (Verified 8/12/16)
Department of Finance
ARGUMENTS IN SUPPORT: This bill is sponsored by Western Center on Law and Poverty (WCLP) to put in place policies and procedures to allow people moving between Medi-Cal and Covered California to do so without being uninsured. WCLP writes that many people moving between programs are ending up without health coverage for one to several months despite an existing law provision that requires that individuals be able to move between programs without any breaks in coverage. During gaps in coverage, individuals cannot get the care they need, or they have to pay for care out-of-pocket, which many cannot afford. WCLP argues that when people move from Covered California to Medi-Cal, the state is planning to change its policy of “presumptive eligibility” which enrolls them in Medi-Cal quickly. WCLP states the effect of this change which will be that people will have to say on Covered California while the county makes a final Medi-Cal eligibility determination. WCLP states this forces the person to pay premiums and cost-sharing as if they had higher income when Medi-Cal coverage is free. For individuals moving from Covered Coverage to Medi-Cal, WCLP writes this bill ensures their case is sent to the county right away and is promptly determined. Finally, WCLP writes that this bill also ensures that individuals moving from Medi-Cal to Covered California are being told they most choose a Covered California plan to avoid a break in coverage, and will allow consumers more time to choose and enroll in a Covered California plan.
ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes because it creates additional General Fund costs for DHCS and the Department of Social Services. In addition, DOF states this bill is unnecessary and premature as DHCS and Covered California are already taking steps to address the concerns raised in this bill by planning for the implementation of CalHEERS functionality to address this issue. DOF states that DHCS and the Covered California are already undertaking efforts to improve the transition of beneficiaries between Medi-Cal and QHP coverage, and CalHEERS functionality is scheduled to be implemented in October of 2016 to enhance automation processes for insurance affordability programs transitions.
ASSEMBLY FLOOR: 80-0, 6/2/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon
8/15/16 20:27:03
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SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
AB 2077 (Burke) - Health Care Eligibility, Enrollment, and Retention Act
Version: June 27, 2016 | Policy Vote: HEALTH 9 - 0 |
Urgency: No | Mandate: Yes |
Hearing Date: August 8, 2016 | Consultant: Brendan McCarthy |
This bill meets the criteria for referral to the Suspense File.
Bill Summary:
AB 2077 would extend Medi-Cal eligibility in some circumstances and impose deadlines for determining Medi-Cal eligibility, in order to avoid gaps in coverage for beneficiaries transitioning between Medi-Cal and Covered California health care coverage.
Fiscal Impact:
- One-time costs in the hundreds of thousands, for the Department of Health Care Services to change internal processes, revise regulations, and seek any necessary federal approvals (General Fund and federal funds).
- One-time costs in the hundreds of thousands to make system changes to several information technology systems used to determine eligibility for Medi-Cal and Covered California coverage and to manage Medi-Cal enrollment (General Fund and federal funds). In order to facilitate the requirements of the bill, system changes will be needed to CalHEERS (the system used to process applications for Medi-Cal and Covered California coverage) and MEDS (the system used to managed Medi-Cal enrollment). It is possible that those costs would be eligible for enhanced federal matching rate of 90%.
- One-time costs of $2.5 million to make system changes to the SAWS (the systems used by counties to determine eligibility for Medi-Cal) (General Fund and federal funds).
- Ongoing costs of $3 million to $5 million per year from extended Medi-Cal eligibility during transitions to Covered California coverage (General Fund and federal funds). Under current practice, when an individual loses eligibility for Medi-Cal (generally because of an increase in income), the individual is given 10 days’ notice before coverage is terminated. This bill would require individuals to be given 20 days’ notice before coverage is terminated. Medi-Cal coverage would be terminated before 20 days, if the individual enrolls in coverage through Covered California. Because Medi-Cal enrollment is granted monthly, extending the transition period from 10 to 20 days will result in roughly a third of transitioning individuals receiving an additional month of coverage. According to data published by the Department, there are 5,000-6,000 individuals per month who transition from Covered California to Medi-Cal. Staff assumes that a roughly similar number of individuals transition from Medi-Cal to Covered California each month.
- Ongoing costs, potentially in the low millions due to increased enrollment in Medi-Cal of individuals transitioning from Covered California coverage to Medi-Cal (General Fund and federal funds). The bill would impose new deadlines on counties to determine Medi-Cal eligibility for individuals who have lost their Covered California coverage. By imposing such deadlines, the bill may result in earlier Medi-Cal enrollment. If 10% of individuals in that situation become eligible for Medi-Cal for one extra month under the bill, the annual cost would be about $3 million.
Background:
Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household incomes up to 138% of the federal poverty level and to children with household incomes up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.
Also under state and federal law, the state operates Covered California, which is the state’s health benefit exchange. Individuals are able to purchase health care coverage through Covered California, with federal subsidies for individuals with household income up to 400% of the federal poverty level.
Based on changes in household income, individuals and families transition back and forth between Medi-Cal and subsidized Covered California Coverage.
Current law requires transitions between these programs to be accomplished without a break in coverage. However, some of the state’s existing processes and procedures seem to be resulting in coverage lapses (for example, an individual losing Medi-Cal coverage before Covered California coverage begins) or instances in which an individual who is no longer eligible for subsidized Covered California coverage is not yet enrolled in Medi-Cal, leading to additional premium or cost sharing requirements on the individual.
Under current practice, when an individual is no longer eligible for Medi-Cal, a county will send a “notice of action” informing the individual that he or she will shortly lose Medi-Cal coverage. Under current practice, the individual’s Medi-Cal coverage will not be terminated for at least 10 days. Because Medi-Cal coverage is provided monthly, the actual additional coverage period will depend whether the 10 day period goes into the following month (in which case the individual will have an additional month of coverage).
Under current law, counties are generally required to determine eligibility for Medi-Cal within 45 days. For individuals or families who are transitioning from Covered California coverage to Medi-Cal (for example because of a reduction in household income), current practice has been to grant presumptive eligibility, enroll the individual or household in Medi-Cal, and then require counties to make a final eligibility determination. Generally, this has prevented significant gaps in coverage for individuals transitioning to Medi-Cal. (Medi-Cal coverage is granted monthly and is usually retroactive to the first day of the month.) The Department of Health Care Services has indicated that it is going to change this policy and no longer grant presumptive eligibility to this population. The sponsors of the bill are concerned that this could result in coverage gaps, depending on how long it will take counties to determine Medi-Cal eligibility.
Proposed Law:
AB 2077 make extend Medi-Cal eligibility in some circumstances and impose deadlines for determining Medi-Cal eligibility, in order to avoid gaps in coverage for beneficiaries transitioning between Medi-Cal and Covered California health care coverage.
Specific provisions of the bill would:
- If an individual is eligible for coverage through Covered California, prohibit Medi-Cal coverage from being terminated until at least 20 days after the county sends a notice of action notifying the beneficiary that Medi-Cal benefits are being terminated;
- Require the notice of action to inform the beneficiary of the deadline to enroll in Covered California coverage to avoid a gap in coverage;
- Require Medi-Cal coverage to be terminated on the date of enrollment in Covered California coverage, if it is less than 20 days from the notice of action being sent;
- Make implementation contingent on federal financial participation;
- When an beneficiary who had Covered California coverage is determined to be newly eligible for Medi-Cal by CalHEERS, require the state to send the beneficiary’s case information to the county of residence within three days;
- When an beneficiary who had Covered California coverage is determined to be newly eligible for Medi-Cal by CalHEERS, require the county of residence to make a final Medi-Cal eligibility determination by the end of the month for cases received before the 15th of the month, or the 15th day of the following month for cases received after the 15th of the month.
Staff Comments:
As part of the state’s implementation of the Affordable Care Act, the state has created Covered California to provide subsidized health care coverage, expanded Medi-Cal eligibility to childless adults, and created a system designed to provide “no wrong door” for accessing health care coverage. Individuals and families can apply for both Medi-Cal and Covered California coverage online through Covered California, by phone, in person at county welfare offices, or through enrollment counselors. To the consumer, it appears that determining program eligibility and enrolling the applicant in the appropriate health care coverage program is done by the same system. While the CalHEERS computer system is used to determine which program an individual is eligible for, final eligibility determinations and enrollment into Medi-Cal is still primarily performed by counties. (CalHEERS can determine Medi-Cal eligibility when the information provided by the applicant and federal data sharing partners is sufficient to determine eligibility. If information is incomplete or needs further verification of clarification, the resident county performs the eligibility determination.)
Under current practice, when an individual who has Covered California coverage experiences a reduction in income such that they are likely to be eligible for Medi-Cal, the individual is granted presumptive eligibility for Medi-Cal, while the county of residence reviews the case file to make the final eligibility determination. The Department of Health Care Services is about to make a change to this process that would eliminate presumptive eligibility for those individuals. There are indications that most applicants in this situation have their Medi-Cal eligibility determined before their Covered California coverage is terminated. By placing specific timelines in statute for counties to perform the required eligibility determinations, the bill may increase Medi-Cal enrollment, by facilitating earlier enrollments by eligible individuals.
-- END --
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 2077
AUTHOR: | Burke | ||
VERSION: | June 1, 2016 | ||
HEARING DATE: | June 22, 2016 | ||
CONSULTANT: | Scott Bain | ||
SUBJECT: Health Care Eligibility, Enrollment, and Retention Act
SUMMARY:
Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility if the individual is eligible to enroll in a qualified health plan through Covered California, to the extent federal financial participation is available. Establishes application processing timelines for counties for individuals who were enrolled in Covered California and who are determined newly eligible for Medi-Cal through the application processing system known as the California Healthcare Eligibility, Enrollment and Retention System.
Existing federal law
- Requires, under the Patient Protection and Affordable Care Act (ACA, Public Law 111-148), as amended by the Health Care Education and Reconciliation Act of 2010 (Public Law 111-152), each state to establish an American Health Benefit Exchange that makes qualified health plans (QHP) available to qualified individuals and qualified employers. Requires, if a state does not establish an Exchange, the federal government to administer the Exchange.
- Allows through the ACA, eligible individual taxpayers whose household income equals or exceeds 100%, but does not exceed 400% of the federal poverty level (FPL), an advanceable and refundable tax credit (APTC) for a percentage of the cost of premiums for coverage under a QHP offered in the Exchange. The ACA requires a reduction in cost-sharing for individuals with incomes below 250% of the FPL, and a lower maximum limit on out-of-pocket expenses for individuals whose incomes are between 100% and 400% of the FPL.
Existing state law:
- Establishes the California Health Benefit Exchange (known as Covered California) in state government, and specifies its duties and authority. Requires Covered California to be governed by a board that includes the Secretary of the California Health and Human Services Agency and four members with specified expertise who are appointed by the Governor and the Legislature.
- Establishes the Medi-Cal Program, administered by the Department of Health Care Services (DHCS), which provides comprehensive health benefits to low-income children up to 266% of the FPL, parents and adults under age 65 up to 138% of the FPL, pregnant women, and elderly, blind or disabled persons, who meet specified eligibility criteria.
- Requires, during the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for an insurance affordability program (such as Medi-Cal or Covered California) to ensure that an eligible applicant and recipient of insurance affordability programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage.
- Requires counties, for individuals determined ineligible for Medi-Cal by a county following the redetermination procedures, eligibility to be determined for other insurance affordability programs. Requires the county, if the individual is found to be eligible, to transfer the individual’s electronic account to other insurance affordability programs via a secure electronic interface.
- Requires county social service departments to notify beneficiaries in writing of their Medi-Cal-only eligibility or ineligibility, and of any changes made in their eligibility status or share of cost. These notifications are called a “Notice of Action (NOA).” NOAs inform Medi-Cal beneficiaries of:
- Any approval, denial or discontinuance of eligibility;
- A change in the beneficiary’s share of cost;
- The reason an action is being taken and the law or regulation that requires the action (if the action is a denial, discontinuance or increase in share of cost); and,
- The right to request a state hearing.
This bill:
- Prohibits Medi-Cal benefits from being terminated until at least 20 days after the county sends the NOA terminating Medi-Cal eligibility if the individual is eligible to enroll in a QHP through Covered California.
- Requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through the Exchange to avoid being uninsured.
- Requires Medi-Cal eligibility to be terminated as of the date of enrollment in the QHP if the individual has effectuated his or her enrollment in a QHP through Covered California before the termination date specified in the notice.
- Implements paragraphs 1) through 3) above only to the extent that federal financial participation is available.
- Requires, if an individual who has been enrolled in a QHP through Covered California is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS), the individual’s case information and eligibility determination to be sent to his or her county of residence within three business days. (CalHEERS is the on-line application system administered by Covered California and DHCS.)
- Requires cases received by the county prior to the 15th day of the month to be processed for final Medi-Cal eligibility by the county by the end of that month.
- Requires cases received by the county after the 15th day of the month to be processed for final Medi-Cal eligibility by the 15th day of the following month.
- Requires, for an individual who is newly eligible for Medi-Cal, in a county that provides Medi-Cal services under the two-plan model or the geographic managed care plan model, the individual to be enrolled in a Medi-Cal managed care plan according to either of the following:
- Requires, if the QHP the individual was enrolled in through the Covered California is an available Medi-Cal managed care plan in his or her county and that plan has the same or substantially similar provider network, the individual to be assigned to that plan; or,
- Requires the individual to be assigned to a plan using the usual Medi-Cal managed care default algorithm.
- Requires, for an individual who is newly eligible for Medi-Cal, in a county that provides Medi-Cal services under a county organized health system (COHS), the individual to be enrolled into the COHS plan on the first date of Medi-Cal coverage and to be sent the provider directory for the managed care plan.
-States legislative intent to establish procedures to ensure that individuals move between Medi-Cal and Covered California without any breaks in coverage as required under a specified provision of existing law.
FISCAL EFFECT:
According to the Assembly Appropriations Committee:
- Uncertain Information Technology (IT) costs to CalHEERS system (General Fund (GF)/federal/special), to the county-administered Statewide Automated Welfare System (SAWS), and to the Medicaid Eligibility Data System (GF/federal) to effectuate the policy changes. There is already a "change request" to these IT systems planned that will modify eligibility, enrollment and notifications. This change request could potentially be modified to accomplish the bill's requirements at little additional cost. To the extent this bill would require IT changes beyond the scope of the current request, there could be additional costs.
- This bill's requirements could result in unknown but large additional state cost pressure in Medi-Cal. The largest fiscal impact is associated with the creation of a grace period to move from Medi-Cal and enroll in a Covered California plan, where the state would pay for Medi-Cal coverage for a longer period of time in order to extend the window most consumers have to pick a Covered California plan. If even a portion of this projected 2 million stayed on Medi-Cal for an extra month while transitioning from Medi-Cal to Covered California, the state could experience cost in the millions of dollars or more (GF/federal).
PRIOR VOTES:
Assembly Floor: | 80 - 0 |
Assembly Appropriations Committee: | 14 - 0 |
Assembly Health Committee: | 18 - 0 |
COMMENTS:
- Author’s statement. According to the author, this bill eases the transition between plans for those moving from Covered California plans to Medi-Cal and vice versa. For individuals moving from Medi-Cal to Covered California, they will have 20 days before their Medi-Cal benefits expire. Those moving from Covered California to Medi-Cal will also have additional time to select a plan, and receive guidance on how to select a plan. By providing a coverage bridge for Californians transitioning between plans, we can make sure that no one falls through a coverage gap.
- Transitions between coverage programs. Eligibility for Medi-Cal and Covered California APTC and cost-sharing subsidies are based in part on income. Most adults can qualify for Medi-Cal with incomes up to 138% of the FPL ($33,534 a year for a family of four in 2016) and children can qualify with incomes up to 266% FPL ($64,638 for a family of four in 2016). People whose incomes are higher than these thresholds can get health coverage through Covered California and can qualify for subsidies with incomes up to 400% FPL ($97,200 for a family of four in 2016). When an individual experiences a change in income, they may move between the two programs. These transitions can occur during the course of the year as a result of a change in income, due to a change in the FPL, when an individual has a change in family size, or at annual eligibility redetermination. When an individual’s income increases or decreases, they can move from Medi-Cal to Covered California or vice versa.
DHCS indicates (based on prior years’ data), approximately 80,000 to 100,000 cases transitioned from Covered California to Medi-Cal in the January timeframe, due to Covered California’s annual renewal period (which ends December 31st of each year). An additional 5,000 to 10,000 cases transition from Covered California to Medi-Cal on a monthly basis throughout the remainder of the year, due to reported changes in circumstances. Based on DHCS’ data, on average 2,800 – 5,000 Medi-Cal cases transition each month to Covered California.
Existing law already requires transitions between the programs without a break in coverage. This bill establishes more specific provisions on how transitions from Medi-Cal to Covered California (and vice versa) will work, as follows:
- Covered California to Medi-Cal. When an individual moves from coverage in Covered California to Medi-Cal through CalHEERS, this bill requires that case information to be sent to their county of residence within three business days (Covered California indicates this information is transmitted immediately under current practice).
Under existing law, counties receiving these cases have 45 days to make a Medi-Cal eligibility determination for most cases. Under this bill, shorter timeframes would apply for these individuals. Cases received by the county prior to the 15th day of the month would have to be processed for final Medi-Cal eligibility by the county by the end of that month. Cases received after the 15th day of the month would have to be processed for final Medi-Cal eligibility by the 15th day of the following month. The purpose of these shorter timeframes is so that individuals are not required to incur premiums and cost-sharing for Covered California coverage when they are Medi-Cal eligible. - Medi-Cal to Covered California. When an individual moves from Covered California to Medi-Cal, this bill would prohibit Medi-Cal benefits from being terminated until at least 20 days after the county sends a NOA terminating Medi-Cal eligibility. Under current law, NOAs are sent 10 days prior to Medi-Cal eligibility being discontinued. In addition, this bill would require Medi-Cal eligibility to be terminated as of the date of enrollment in the QHP in Covered California if the individual has effectuated his or her enrollment in a QHP through Covered California before the termination date contained in the notice.
There are several reasons for this longer timeframe. Because Medi-Cal coverage is a monthly basis, a notice mailed mid-month would not meet the 20 day notice, so Medi-Cal coverage would continue through the following month. For example, if Medi-Cal coverage was discovered to be discontinued on March 12, the 20 day notice requirement would mean the coverage discontinuance would not take effect until May 1st,(because the 20 day notice would fall after the end of March). Under a 10 day NOA requirement, the individual’s coverage would terminate April 1st. In addition, the 20 day notice provides an individual a longer time period to select a QHP in Covered California. To address DHCS’ concern that this would result in a state-only Medi-Cal cost for an additional month of Medi-Cal coverage, this bill contains language making this provision contingent upon FFP being available.
In addition, this bill requires the NOA to inform the individual of the date by which he or she must select and enroll in a QHP through the Exchange to avoid being uninsured. This provision addresses an issue with the existing notices, which do not notify individuals of the need for prompt action if they do not pick a QHP so as to avoid a gap between when their Medi-Cal coverage ends and their Covered California coverage begins. The notice fixes are currently scheduled for implementation in September 2016.
- Prior legislation. AB 1296 (Bonilla, Chapter 641, Statutes of 2011) enacted the Health Care Eligibility, Enrollment and Retention Act, requiring state entities who administer health care coverage programs to undertake a variety of activities related to eligibility, enrollment and renewal of health care coverage through Medi-Cal.
- Support. This bill is sponsored by Western Center on Law and Poverty (WCLP) to put in place policies and procedures to allow people moving between Medi-Cal and Covered California to do so without being uninsured. WCLP writes that many people moving between programs are ending up without health coverage for one to several months despite an existing law provision that requires that individuals be able to move between programs without any breaks in coverage. During gaps in coverage, individuals cannot get the care they need, or they have to pay for care out-of-pocket, which many cannot afford. WCLP argues that when people move from Covered California to Medi-Cal, the state is planning to change its policy of “presumptive eligibility” which enrolls them in Medi-Cal quickly. WCLP states the effect of this change which will be that people will have to say on Covered California while the county makes a final Medi-Cal eligibility determination. WCLP states this forces the person to pay premiums and cost-sharing as if they had higher income when Medi-Cal coverage is free. For individuals moving from Covered Coverage to Medi-Cal, WCLP writes this bill would ensure their case is sent to the county right away and is promptly determined. Finally, WCLP writes that this bill would also ensure that individuals moving from Medi-Cal to Covered California are being told they most choose a Covered California plan to avoid a break in coverage, and will allow consumers more time to choose and enroll in a Covered California plan.
The Legal Aid Society of Orange County, Legal Services of Northern California and the Legal Aid Society of San Mateo County writes in support of this measure and cites cases they have dealt with where individuals transitioning between Medi-Cal and Covered California have had gaps in coverage, and have suffered adverse health and financial consequences as a result. - DHCS concerns. The problems with transitions between Covered and Medi-Cal has been discussed with DHCS and Covered California, and the improved notices regarding the need to promptly pick a plan for new Covered California enrollees are currently scheduled to take effect in the CalHEERS release in September 2016. With regard to the 20 day NOA (instead of the current 10 day NOA), DHCS indicates this change would treat individuals in a transition differently than new applicants for Medi-Cal coverage. This change would require changes to DHCS’ existing infrastructure for a subset of individuals, and is counter to DHCS’ desire to treat individuals the same. If the NOA timeframe were changed to 20 days for all Medi-Cal beneficiaries, DHCS indicates this would have an impact on Medi-Cal costs as more individuals would remain on the program an additional month.
- Author’s amendment. The author is proposing to delete the provisions in this bill that assign people moving from Covered California to a Medi-Cal into a Medi-Cal managed care plan.
SUPPORT AND OPPOSITION:
Support: Western Center on Law and Poverty (sponsor)
American Cancer Society Cancer Action Network
Asian Americans Advancing Justice
Asian Law Alliance
California Black Health Network
California Pan-Ethnic Health Network
California Coverage and Health Initiatives
California Immigrant Policy Center
California Rural Legal Assistance, Inc.
California School Employees Association
Central California Legal Services, Inc.
Children Now
Children’s Defense Fund
Children’s Partnership
Coalition of Welfare Rights Organizations, Inc.
Congress of California Seniors
Consumers Union
Health Access California
Justice in Aging
Legal Aid Society of Orange County
Legal Aid Society of San Mateo County
Legal Services of Northern California
National Association of Social Workers, California Chapter
National Health Law Program
Project Inform
Oppose: None received
-- END --
(Without Reference to File)
ASSEMBLY THIRD READING
ATR Bill Id:AB 2077
Author:(Burke and Bonilla)
As Amended Ver:June 1, 2016
Majority vote
Committee | Votes | Ayes | Noes |
Health | 18-0 | Wood, Maienschein, Bonilla, Burke, Chiu, Dababneh, Gomez, Roger Hernández, Lackey, Nazarian, Olsen, Patterson, Ridley-Thomas, Rodriguez, Santiago, Steinorth, Thurmond, Waldron | |
Appropriations | 14-0 | Gonzalez, Bloom, Bonilla, Bonta, Calderon, Daly, Eggman, Eduardo Garcia, Roger Hernández, Holden, Quirk, Santiago, Weber, Wood |
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SUMMARY: Establishes procedures to ensure eligible recipients move from Medi-Cal and other insurance affordability programs, like the California Health Benefit Exchange (Exchange) or CoveredCA), without any breaks in coverage. Prohibits, for individuals eligible to enroll in a qualified health plan (QHP) through the Exchange, Medi-Cal benefits from being terminated until at least 20 days after the county sends the notice of action terminating Medi-Cal eligibility (Medi-Cal to CoveredCA transition) and is contingent to the extent that federal financial participation is available. Specifies procedures counties must follow to enroll individuals in Medi-Cal who are deemed ineligible for subsidized coverage through the Exchange due to income that appears to make them Medi-Cal eligible (CoveredCA to Medi-Cal transition).
FISCAL EFFECT: According to the Assembly Appropriations Committee:
- Uncertain Information Technology (IT) costs to the California Healthcare Enrollment, Eligibility and Retention System (CalHEERS) system (General Fund (GF)/federal/special), to the county-administered Statewide Automated Welfare System (SAWS), and to the Medicaid Eligibility Data System (GF/federal) to effectuate the policy changes. There is already a "change request" to these IT systems planned that will modify eligibility, enrollment and notifications. This change request could potentially be modified to accomplish the bill's requirements at little additional cost. To the extent this bill would require IT changes beyond the scope of the current request, there could be additional costs.
- This bill's requirements could result in unknown but large additional state cost pressure in Medi-Cal. The largest fiscal impact is associated with the creation of a grace period to move from Medi-Cal and enroll in a CoveredCA plan, where the state would pay for Medi-Cal coverage for a longer period of time in order to extend the window most consumers have to pick a CoveredCA plan. If even a portion of this projected 2 million stayed on Medi-Cal for an extra month while transitioning from Medi-Cal to CoveredCA, the state could experience cost in the millions of dollars or more (GF/federal).
COMMENTS: The sponsor, Western Center on Law and Poverty (WCLP), states that under the existing presumptive eligibility process, most people do not have a break in coverage during which they are uninsured. However, a change in policy at the state level may result in individuals being required to stay in CoveredCA until they have their Medi-Cal eligibility determined while paying premiums for commercial coverage. Furthermore, the Department of Health Care Services (DHCS) selects the Medi-Cal plan based on their QHP plan, even when networks are different. Unlike Medi-Cal, CoveredCA coverage cannot begin until the individual has chosen a QHP plan. According to the sponsor, individuals whose Medi-Cal coverage are ending are not told to choose a CoveredCA plan before the end of the month to avoid a break in coverage.
Federal Poverty Level (FPL) is a measure of income level issued annually by the Department of Health and Human Services to determine eligibility for certain programs and benefits. Medi-Cal is available to all individuals who qualify on the basis of income up to 138% of the FPL and all children (up to age 19) whose family's income is at or under 266% of the FPL. Families who enroll in the Exchange with income below 266% of the FPL must enroll their children in Medi-Cal or enroll their children into a separate commercial plan.
The Exchange does not change how existing state health care coverage programs are administered. Medi-Cal continues to be administered by the DHCS. Federal law requires state exchanges to perform the function of screening for and enroll individuals in Medi-Cal. The Exchange coordinates with DHCS and California counties to ensure that individuals are seamlessly transitioned between coverage programs if their eligibility changes.
CalHEERS is the computer system behind the Exchange and is sponsored by CoveredCA and DHCS. It is a computer program that allows prospective consumers to enter their personal and income data and receive information about plans they are eligible for and what they cost. It also determines preliminary eligibility for Advanced Premium Tax Credits, Modified Adjusted Gross Income (MAGI) Medi-Cal, and Non-MAGI Medi-Cal.
Consumers who experience a qualifying life event can enroll in a CoveredCA health insurance plan even outside of the open-enrollment period. This is called special enrollment and includes income changes in which a consumer becomes newly eligible or ineligible for help paying for their insurance. Medi-Cal enrollment is year-round.
While existing law already requires transitions between CoveredCA and Medi-Cal without a break in coverage, this bill provides for specificity with respect to notice requirements for newly eligible members. Unlike Medi-Cal, CoveredCA coverage cannot begin until the individual has chosen a QHP, however it appears as if current notices are insufficient to advise individuals that they need to choose a QHP before the end of the month to avoid a break in health coverage. This bill also requires CalHEERS to send an individual's case file within a specific time if CalHEERS receives information indicating that an individual is newly eligible for Medi-Cal.
WCLP, the sponsor of this bill, states that while existing law requires transitions between Medi-Cal and CoveredCA without a break in coverage, there needs to be more specific processes to ensure that the transitions work. WCLP writes that the state is changing its current processes and even when someone loses their job and reports it to CoveredCA, they would have to stay on and keep paying for their current coverage, rather than moving over to Medi-Cal. WCLP and the Asian Law Alliance also contend that this bill will put policies in place to ensure that when someone's income fluctuates they could move into their new program without becoming uninsured.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003374
Date of Hearing: April 20, 2016
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
ABPCA Bill Id:AB 2077
Author:(Burke) – As Amended Ver:March 18, 2016
Policy Committee: | Health | Vote: | 18 - 0 |
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Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill establishes specific procedures to ensure eligible recipients move from Medi-Cal and other insurance affordability programs such as the California Health Benefit Exchange (CoveredCA), without any breaks in coverage as required by current law. Specifically, this bill:
- Establishes a grace period for persons no longer eligible for Medi-Cal, during which Medi-Cal benefits are not terminated unless an individual enrolls in another health plan before the specified termination date (Medi-Cal to CoveredCA transition).
- Specifies procedures counties must follow to enroll individuals in Medi-Cal who are deemed ineligible for subsidized coverage through Covered California due to income that appears to make them Medi-Cal eligible (CoveredCA to Medi-Cal transition).
- Specifies other requirements related to the content of notices and related administrative procedures.
FISCAL EFFECT:
- Uncertain Information Technology (IT) costs to the CalHEERS system (GF/federal/special), to the county-administered Statewide Automated Welfare System (SAWS), and to the Medicaid Eligibility Data System (MEDS) (GF/federal) to effectuate the policy changes. There is already a "change request" to these IT systems planned that will modify eligibility, enrollment and notifications. This change request could potentially be modified to accomplish the bill's requirements at little additional cost. To the extent this bill would require IT changes beyond the scope of the current request, there could be additional costs.
- This bill's requirements could result in unknown but large additional state cost pressure in Medi-Cal. Although current law requires the state to provide for a seamless transition, to the extent the specific procedures required by this bill preclude the state from pursuing other, most cost-efficient ways to ensure individuals seamlessly move between programs, costs would increase beyond the status quo, even when considering currently planned changes.
The largest fiscal impact is associated with the creation of a grace period to move from Medi-Cal and enroll in a CoveredCA plan, where the state would pay for Medi-Cal coverage for a longer period of time in order to extend the window most consumers have to pick a CoveredCA plan. This bill would prohibit Medi-Cal eligibility from being terminated until at least 30 days after the county sends a "notice of action" about the termination, allowing individuals to stay on Medi-Cal longer than they otherwise would. Based on the fact that eligibility is provided on a monthly basis, it appears this bill would provide additional time to about 2/3 of the individuals enrolling in CoveredCA from Medi-Cal. Under current rules, these individuals would have been terminated from enrollment at the end of the month in which they were determined ineligible, whereas under this bill they would gain another month of eligibility.
The UC Berkeley Labor Center estimated around 16%, or 2 million beneficiaries, would be income-eligible to transition out of Medi-Cal to CoveredCA every year. This is likely an overestimate, but the "churn" between programs is nevertheless significant. If even a portion of this projected 2 million stayed on Medi-Cal for an extra month while transitioning from Medi-Cal to CoveredCA, the state could experience cost in tens of millions. It is unknown precisely what the overall cost of this grace period would be. It would depend on the number of such transitions, which is not currently reported, and how long they would stay on the program under the new rules versus the status quo. Over a large base of beneficiaries, small changes can have an enormous fiscal effect.
Finally, it is unclear whether federal rules allow for federal financial participation (FFP) during this proposed coverage grace period as currently envisioned by this bill. If federal rules do not allow FFP, any costs would be state-only GF costs.
COMMENTS:
- Purpose. Current law requires the state to ensure individuals can transition between insurance affordability programs without a gap in coverage. This bill intends to establish specific administrative procedures that effectuate this broad requirement. Western Center on Law and Poverty (WCLP), this bill's sponsor, believes such specific guidance is necessary in order to ensure individuals are enrolled into Medi-Cal in a timely way, and to meet other goals such as encouraging individuals to select a Medi-Cal plan and ensuring they receive timely and accurate information about eligibility. It attempts to make the process consumer-friendly without being overly burdensome on the state administration of the programs.
- Background. CalHEERS is the computer system that operates as a single online portal to apply for state health care affordability programs, including Medi-Cal and premium subsidies through CoveredCA. The transition between these programs— when individuals lose eligibility for one program and gain eligibility for another due to changes in income or family size— is the subject of this bill. Adults are generally eligible for Medi-Cal if they make under 138% of the poverty level, while higher levels apply to children and different rules apply to seniors. An individual receiving Medi-Cal or CoveredCA subsidies is supposed to report a change in income to CalHEERS in order to re-determine the benefits for which one is eligible. Many transitions also occur during required annual redeterminations.
Transitioning from Medi-Cal to subsidized coverage is different than transitioning in the other direction. The differences include:
- Currently, applications for persons who appear Medi-Cal eligible due to income are forwarded to county eligibility offices to make a final determination for Medi-Cal eligibility, while CalHEERS makes a final determination for CoveredCA subsidies.
- Medi-Cal plan selection can be done through a default algorithm, while individuals must actively select a plan and pay premiums in order to enroll in a CoveredCA plan.
- Although Medi-Cal enrollment is year-round, individuals can only choose plans and receive subsidized coverage through CoveredCA during open enrollment periods or if they experience a qualifying life event, such as a change in income.
This bill attempts to address some of these nuances by specifying certain processes that apply in each case, such as timelines and notice requirements for Medi-Cal plan selections. Currently, CoveredCA and DHCS are conducting stakeholder workgroups to address concerns with such transitions.
- Prior Legislation. AB 1296 (Bonilla), Chapter 641, Statutes of 2011, enacts the Health Care Reform Eligibility, Enrollment, and Retention Planning Act (Act), which requires the California Health and Human Services Agency (CHHSA), in consultation with specified entities, to establish standardized single, accessible application forms and related renewal procedures for state health subsidy programs, as defined, in accordance with specified requirements. It also addressed coverage transitions, requiring "during the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for a public health coverage program shall ensure that an eligible applicant and recipient of state health subsidy programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary."
- Staff Comments. This bill offers a specific solution to implement a current-law requirement for seamless coverage transitions that the author contends has not yet been realized. Staff notes there may be other workable solutions available that are consumer-friendly but at a lower state cost. At the very least, implementing a process contingent on whether federal matching funds are available seems reasonable.
It does not appear that information about the number and seamlessness of transitions is meaningfully tracked at this time, raising questions about whether the state is able to monitor its own compliance with current state law, which specifies individuals should move between programs with any breaks in coverage. It is difficult to demonstrate the extent of a problem or measure progress without this data. According to DHCS, this data will soon be reported and monitored as part of a report required pursuant to AB X1 1 (J. Perez), Chapter 3, Statutes of 2013
Finally, there is an inherent tension between maintaining seamless coverage and providing consumers adequate time to make informed decisions about plan choice, if appropriate. There is also a tension between the state's interest in maintaining seamless coverage and minimizing its growing burden of health care costs. There is not likely to be a solution that optimizes all of the variables at once— instead, the question is how the state should balance these trade-offs.
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
Date of Hearing: April 5, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 2077 (
Author:Burke) – As Amended Ver:March 18, 2016
SUBJECT: Health Care Eligibility, Enrollment, and Retention Act.
SUMMARY: Establishes procedures to ensure eligible recipients move from Medi-Cal and other insurance affordability programs, like the California Health Benefit Exchange (Exchange), without any breaks in coverage. Specifically, this bill:
- Prohibits, for individuals eligible to enrollee in a qualified health plan (QHP) through the Exchange, Medi-Cal benefits from being terminated until at least 30 days after the county sends the notice of action terminating Medi-Cal eligibility.
- Requires the notice of action to inform an individual of the date by which he or she must select and enroll in a QHP to avoid being uninsured. Specifies that if an individual enrolls in a QHP before the notice of action termination date, Medi-Cal eligibility will be terminated at the QHP enrollment date.
- Requires an individual’s case to be run through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) when a QHP enrollee reports a change in circumstances, goes through the renewal process, or is reevaluated for eligibility and there is a change affecting his or her eligibility for any insurance affordability program. Requires CalHEERS to send an individual’s case file to his or her county of residence within three business days if CalHEERS receives information indicating that an individual enrolled in a QHP is newly eligible for Medi-Cal. Specifies that the county:
- Cannot treat the individual as a new Medi-Cal application;
- Must process case files received before the 15th of the month for final Medi-Cal eligibility by the end of that month and case files received after the 15th of the month by the 15th day of the following month;
- Issue a notice at least 15 days before the individual’s QHP enrollment ends that advises the following: he or she will be Medi-Cal enrolled; instructions on how to select a Medi-Cal managed care plan; right to appeal QHP eligibility; and, instructions on how to request continued enrollment in a QHP pending the outcome of his or her appeal;
- Verify income, as specified;
- Must follow procedures for newly eligible Medi-Cal individuals. For Medi-Cal counties under the two-plan model or the geographic managed care plan model, the individual will be enrolled to either the available Medi-Cal managed care plan that has the same or substantially similar provider network to the QHP plan or to a plan using the usual Medi-Cal managed care default algorithm;
- Issue a 15 day notice to the individual and include: the assigned Medi-Cal managed care plan if the individual does not take any action; the individual choice of any available plan; description of available Medi-Cal managed care plans; and, instructions on how to change Medi-Cal managed care plans; and,
- For counties under a county organized health system (COHS) to enroll an individual on the first date of Medi-Cal coverage and send the provider directory to the individual.
EXISTING LAW:
- Establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the state’s children’s health insurance program (CHIP).
- Establishes the Medi-Cal program which is administered by the Department of Health Care Services (DHCS), under which qualified low-income persons receive health care benefits. Governs and funds the Medi-Cal program, in part, by federal Medicaid program provisions. Allows DHCS to exercise a specified federal option to extend continuous Medi-Cal eligibility to children 19 years of age and younger.
- Establishes the Exchange, also referred to as Covered California (CoveredCa) within state government, as an independent public entity not affiliated with an agency or department, and requires the Exchange to compare and make available through selective contracting health insurance for individual and small business purchasers as authorized under the federal Patient Protection and Affordable Care Act (ACA). Specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of qualified health plans though the Exchange by qualified individuals and small employers.
- Requires the board to determine the criteria and process for eligibility, enrollment, and disenrollment of enrollees and potential enrollees in the Exchange and coordinate that process with state and local government entities administering other specified health care coverage programs, as specified
- Requires an individual to be provided the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means.
- Defines “insurance affordability programs” to include the Medi-Cal program, CHIP, and a program that makes available to qualified individuals coverage in a QHP through the Exchange with advance payment of the premium tax credit established under the Internal Revenue Code and cost-sharing reduction under federal law.
- Requires an entity making eligibility determination for an insurance affordability program to ensure than an eligible applicant and recipient of the program meets all program eligibility requirements and complies with all necessary requirements for information without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. The sponsor, Western Center on Law and Poverty (WCLP), states that under the existing presumptive eligibility process, most people do not have a break in coverage during which they are uninsured. However, a change in policy at the state level may result in individuals being required to stay in CoveredCa until they have their Medi-Cal eligibility determined while paying premiums for commercial coverage. Furthermore, DHCS selects the Medi-Cal plan based on their QHP plan, even when networks are different and without giving the individual a choice of plan. Unlike Medi-Cal, CoveredCa coverage cannot begin until the individual has chosen a QHP plan. According to the sponsor, individuals whose Medi-Cal coverage are ending are not told to choose a CoveredCa plan before the end of the month to avoid a break in coverage.
- BACKGROUND.
- Federal Poverty Level (FPL). FPL is a measure of income level issued annually by the Department of Health and Human Services to determine eligibility for certain programs and benefits. Medi-Cal is available to all individuals who qualify on the basis of income up to 138% of the FPL and all children (up to age 19) whose family’s income is at or under 266% of the FPL. Families who enroll in the Exchange with income below 266% of the FPL must enroll their children in Medi-Cal or enroll their children into a separate commercial plan.
- CoveredCa. The Exchange does not change how existing state health care coverage programs are administered. Medi-Cal continues to be administered by the DHCS. Federal law requires state exchanges to perform the function of screening for and enroll individuals in Medi-Cal. The Exchange coordinates with DHCS and California counties to ensure that individuals are seamlessly transitioned between coverage programs if their eligibility changes.
- CalHEERS. CalHEERS is the computer system behind the Exchange and is sponsored by CoveredCa and DHCS. It is a computer program that allows prospective consumers to enter their personal and income data and receive information about plans they are eligible for and what they cost. It also determines preliminary eligibility for Advanced Premium Tax Credits, Modified Adjusted Gross Income (MAGI) Medi-Cal, and Non-MAGI Medi-Cal.
- Enrollment. Consumers who experience a qualifying life event can enroll in a CoveredCa health insurance plan even outside of the open-enrollment period. This is called special enrollment and includes income changes in which a consumer becomes newly eligible or ineligible for help paying for their insurance. Medi-Cal enrollment is year-round.
- Existing transition procedures. While existing law already requires transitions between CoveredCa and Medi-Cal without a break in coverage, this bill provides for specificity with respect to notice requirements for newly eligible members. Unlike Medi-Cal, CoveredCa coverage cannot begin until the individual has chosen a QHP, however it appears as if current notices are insufficient to advise individuals that they need to choose a QHP before the end of the month to avoid a break in health coverage. This bill also requires CalHEERS to send an individual’s case file within a specific time if CalHEERS receives information indicating that an individual is newly eligible for Medi-Cal.
- SUPPORT. WCLP, the sponsor of this bill, states that while existing law requires transitions between Medi-Cal and CoveredCa without a break in coverage, there needs to be more specific processes to ensure that the transitions work. WCLP writes that the state is changing its current processes and even when someone loses their job and reports it to CoveredCa, they would have to stay on and keep paying for their current coverage, rather than moving over to Medi-Cal. WCLP contend that individuals should be informed of their option to choose their own plan instead of Medi-Cal enrolling individuals into a Medi-Cal plan based on their QHP plan. Additionally, WCLP notes that this bill would give consumers notice at least 30 days before Medi-Cal termination to allow time for consumers to choose and enroll in a QHP plan. Finally, WCLP and the Asian Law Alliance contend that this bill will put policies in place to ensure that when someone’s income fluctuates they could move into their new program without becoming uninsured.
The California Black Health Network states that this bill will ease the transition for consumers and will ensure that no Californian falls through the coverage gap. The California Immigrant Policy Center contends that while the transitions between Medi-Cal and CoveredCa are supposed to happen without a break in coverage, many people are ending up uninsured which means that low and moderate income Californians who are eligible for health coverage are going without care. - RELATED LEGISLATION. AB 1839 (Patterson) allows families in which adults are eligible for subsidized coverage via the Exchange to enroll children eligible for Medi-Cal coverage in the same Exchange product. AB 1839 is pending in Assembly Health Committee.
- PREVIOUS LEGISLATION.
- AB 1296 (Bonilla), Chapter 641, Statutes of 2011, enacts the Health Care Reform Eligibility, Enrollment, and Retention Planning Act (Act), which would require the California Health and Human Services Agency (CHHSA), in consultation with specified entities, to establish standardized single, accessible application forms and related renewal procedures for state health subsidy programs, as defined, in accordance with specified requirements. AB 1296 specifies the duties of the CHHSA and DHCS under the Act, and requires CHHSA to provide specified information to the Legislature by July 1, 2012, regarding policy changes needed to implement the Act.
- SB 970 (De León) of 2012 would have provided for a workgroup of county staff, advocates, legislative staff, and other specified representatives to consider the feasibility, costs, and benefits of integrating application and renewal processes for additional human services and work support programs with the single stated application. SB 970 was vetoed by the Governor who indicated that “this bill is well-intentioned but overly prescriptive in its requirements. Codifying another workgroup and requiring another report are not necessary.”
- POLICY COMMENT. Currently, CoveredCa and DHCS are conducting stakeholder workgroups to address concerns with QHP and Medi-Cal transitions. This bill will assist with codifying specific requirements with respect to timing issues and notice language to ensure that eligibility requirements are met without any break in coverage.
REGISTERED SUPPORT / OPPOSITION:
Support
Western Center on Law and Poverty (sponsor)
Advancing Justice California
Asian Law Alliance
California Black Health Network
California Immigrant Policy Center
Central California Legal Services, Inc.
Consumers Union
Health Access California
Justice in Aging
Legal Aid Society of San Mateo
Legal Services of Northern California
National Health Law Program
Project Inform
Opposition
None on file.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097
Discussed in Hearing
1MIN
Assembly Floor
2MIN
Senate Floor
4MIN
Senate Standing Committee on Health
1MIN
Assembly Floor
Bill Co-Author(s):