Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires Medi-Cal benefits of an individual who is an inmate of a public institution to be suspended effective the date the individual becomes an inmate of a public institution. Existing law requires the suspension to end on the date that the individual is no longer an inmate of a public institution or one year from the date they become an inmate of a public institution, whichever is sooner. Existing law generally requires a county to redetermine a Medi-Cal beneficiarys eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiarys circumstances that may affect their eligibility for Medi-Cal benefits.

This bill would, commencing October 1, 2020, and subject to federal approval, for individuals under 26 years of age, instead require the suspension of Medi-Cal eligibility to end either on the date that the individual is no longer an inmate of the public institution or is no longer otherwise eligible for benefits under the Medi-Cal program, whichever is sooner, and would require the department, in consultation with specified stakeholders, to develop and implement a simplified annual redetermination of eligibility for individuals under 26 years of age whose eligibility is suspended pursuant to these provisions. Because counties are required to make Medi-Cal eligibility determinations, and the bill would expand Medi-Cal annual redetermination of eligibility for certain inmates of public institutions, the 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 the statutory provisions noted above.

GOVERNOR'S VETO

GV Bill Id:AB 914

Author:(Holden)

As Enrolled Ver:September 11, 2019

2/3 vote

SUMMARY:

Extends the duration during which Medi-Cal benefits are suspended when an individual under age 26 is an inmate of a public institution until the individual is no longer an inmate or is no longer eligible, whichever occurs sooner, instead of the existing time-limited suspension of benefits under existing law of one year from the date the person became an inmate or one year or until the individual is no longer eligible, whichever occurs sooner. Makes this change effective October 1, 2020. Requires, until October 1, 2020, the current time-limited suspension to apply unless otherwise set forth under federal law (which requires suspension without a time limit but only for incarcerated former foster youth until age 26). Requires, if any provision of this bill and the existing law this bill amends, conflicts or does not comply with federal law, only that provision to be inoperative. Requires the Department of Health Care Services to develop and implement a simplified annual redetermination of eligibility for individuals under age 26 whose eligibility is suspended.

The Senate Amendments:

Delay the state law change in this bill to October 1, 2020, and require (prior to October 1, 2020) suspension to end under existing state law provisions unless otherwise set forth under federal law (which requires suspension without a time limit for incarcerated former foster youth until age 26). Narrow the existing law inoperability provision, which makes the entire existing law suspension provisions inoperative. Under the Senate amendments, only the provision in existing law and this bill that is in conflict with federal would be inoperative.

Governor’s Veto Message:

This bill would, commencing October 1, 2020, require an indefinite suspension of Medi-Cal benefits for incarcerated individuals under 26 years of age to either end on the date of release from incarceration or when the individuals are no longer otherwise eligible for Medi-Cal benefits, whichever is sooner.

The bill has different age thresholds for indefinite suspension of benefits from those in federal law, resulting in violation of federal comparability requirements that would result in significant General Fund costs.

COMMENTS:

BACKGROUND. Existing federal law prevents Medicaid benefits from being paid for incarcerated individuals except when the inmate is a patient in a medical institution. While incarceration generally excludes inmates from Medicaid payments (except for inpatient services provided outside the prison), federal law does not make them ineligible for Medicaid. The Centers for Medicare and Medicaid Services (CMS) published a letter of guidance in 2016 stating that incarceration does not preclude an inmate from being determined Medicaid eligible. In addition, to promote continuity of care, CMS encouraged states to place the inmate in suspended eligibility status during the period of incarceration, or to implement a claims processing provision to ensure that services are limited to only inpatient services. Suspension of Medi-Cal coverage is effective the date an individual becomes an inmate of a public institution, allowing an inmate to retain eligibility status for Medi-Cal but prohibiting receipt of benefits during incarceration. Termination removes an individual from the state's Medi-Cal database and requires submission of a new application after release from jail or prison.

HR 6 aND Medi-Cal for incarcerated persons. Under current state law, Medi-Cal beneficiaries who become incarcerated have their benefits suspended for one year or until they are released, whichever comes first. For those incarcerated for less than one year, coverage is reinstated by Department of Health Care Services upon release. Anyone over the age of 18 who is incarcerated for longer than one year has their Medi-Cal coverage terminated. Due to recent changes in federal law made in 2018 by HR 6 (Public Law 115-271), known as the "Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act," juveniles who are inmates of public institutions can no longer have a time-limited suspension of Medicaid. HR 6 defined "juveniles" as individuals under to age 21 and former foster youth up to age 26. This federal changes means the one year state law limit for Medi-Cal benefit suspension must be conformed to federal law this population.

According to the Author:

Compared to other individuals in the community, these incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying for Medi-Cal is detrimental to an individual's health outcomes and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual's life after release.

Arguments in Support:

The California State Association of Counties (CSAC) and the County Welfare Directors Association (CWDA) write in support that this bill would allow county welfare departments to continue to suspend eligibility for Medi-Cal for incarcerated individuals past one year to avoid unnecessary workload and ensure that individuals are eligible for critical health and behavioral health services upon release. CWDA and CSAC write that current law requires counties to suspend Medi-Cal eligibility for individuals who become incarcerated for up to one year from the date of incarceration, or upon release, whichever comes sooner. This current limitation makes it more difficult for individuals who are incarcerated for longer periods of time to obtain Medi-Cal benefits prior to their release from jail or prison. Individuals who become incarcerated and have their Medi-Cal benefits suspended, then subsequently terminated based on the one year limit, are required to re-apply for benefits in order to restore their Medi-Cal eligibility. By indefinitely suspending Medi-Cal benefits, CSAC and CWDA write that this bill ensures that incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release, rather than requiring them to re-apply. This provides continuity in mental health care, physical treatment and prescription medication between the period of incarceration and reintegration into their community. Ensuring all incarcerated persons return home without gaps in health care improves community safety, protects public health and reduces the likelihood of recidivism by ensuring people with medical care needs have immediate access to critical health supports they need for benefits and potentially not have access to care immediately.

Arguments in Opposition:

The Department of Finance (DOF) writes in opposition, arguing this bill creates a potentially significant state reimbursable mandate. Additionally, DOF argues this bill is duplicative of existing services within state prisons, and the cost of this change is more appropriately considered alongside other policy changes in the budget process.

FISCAL COMMENTS:

According to the Senate Appropriations Committee:

1. Costs of $5.98 million ($2.99 million General Fund (GF), $2.99 million federal funds) in fiscal year 2019-20 for annual redetermination costs [$580,000 total funds (TF) ($290,000 GF)] and one-time system modification costs of $5.4 million TF ($2.7 million GF) for the Department of Health Care Services (DHCS).
2. $230,000 (General Fund) for the California Department of Corrections and Rehabilitation's (CDCR's) database systems modification costs to allow interface with DHCS. The information technology modifications would consist of CDCR's Transitional Case Management Program establishing a portal/communication system to track any changes made by DHCS. When an inmate arrives in a California state prison, who is currently receiving Medi-Cal benefits, their information is coded into CDCR's primary electronic database, the Strategic Offender Management System, and automatically shared with the DHCS via a sharing agreement that feeds into DHCS' Medi-Cal system and updates the participant's Medi-Cal/SSI status. Operationally, CDCR would incur an absorbable workload to monitor upon intake and screen Medi-Cal beneficiaries who were under 26 years of age at the time they became an inmate of a public institution.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Wicks, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ASSEMBLY FLOOR: 75-0-5

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, O'Donnell, Obernolte, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Wicks, Wood, Rendon

ABS, ABST OR NV: Boerner Horvath, Cooley, Eduardo Garcia, Muratsuchi, Weber

SENATE FLOOR: 40-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ASSEMBLY FLOOR: 78-0-1

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Muratsuchi

UPDATED:

VERSION: September 11, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0002591

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 914

Author:(Holden)

As Amended Ver:August 30, 2019

Majority vote

SUMMARY:

Extends the duration during which Medi-Cal benefits are suspended when an individual under age 26 is an inmate of a public institution until the individual is no longer an inmate or is no longer eligible, whichever occurs sooner, instead of the existing time-limited suspension of benefits under existing law of one year from the date the person became an inmate or one year or until the individual is no longer eligible, whichever occurs sooner. Makes this change effective October 1, 2020. Requires, until October 1, 2020, the current time-limited suspension to apply unless otherwise set forth under federal law (which requires suspension without a time limit but only for incarcerated former foster youth until age 26). Requires, if any provision of this bill and the existing law this bill amends, conflicts or does not comply with federal law, only that provision to be inoperative. Requires the Department of Health Care Services to develop and implement a simplified annual redetermination of eligibility for individuals under age 26 whose eligibility is suspended.

The Senate Amendments:

Delay the state law change in this bill to October 1, 2020, and require (prior to October 1, 2020) suspension to end under existing state law provisions unless otherwise set forth under federal law (which requires suspension without a time limit for incarcerated former foster youth until age 26). Narrow the existing law inoperability provision, which makes the entire existing law suspension provisions inoperative. Under the Senate amendments, only the provision in existing law and this bill that is in conflict with federal would be inoperative.

COMMENTS:

BACKGROUND. Existing federal law prevents Medicaid benefits from being paid for incarcerated individuals except when the inmate is a patient in a medical institution. While incarceration generally excludes inmates from Medicaid payments (except for inpatient services provided outside the prison), federal law does not make them ineligible for Medicaid. The Centers for Medicare and Medicaid Services (CMS) published a letter of guidance in 2016 stating that incarceration does not preclude an inmate from being determined Medicaid eligible. In addition, to promote continuity of care, CMS encouraged states to place the inmate in suspended eligibility status during the period of incarceration, or to implement a claims processing provision to ensure that services are limited to only inpatient services. Suspension of Medi-Cal coverage is effective the date an individual becomes an inmate of a public institution, allowing an inmate to retain eligibility status for Medi-Cal but prohibiting receipt of benefits during incarceration. Termination removes an individual from the state's Medi-Cal database and requires submission of a new application after release from jail or prison.

HR 6 aND Medi-Cal for incarcerated persons. Under current state law, Medi-Cal beneficiaries who become incarcerated have their benefits suspended for one year or until they are released, whichever comes first. For those incarcerated for less than one year, coverage is reinstated by Department of Health Care Services upon release. Anyone over the age of 18 who is incarcerated for longer than one year has their Medi-Cal coverage terminated. Due to recent changes in federal law made in 2018 by HR 6 (Public Law 115-271), known as the "Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act," juveniles who are inmates of public institutions can no longer have a time-limited suspension of Medicaid. HR 6 defined "juveniles" as individuals under to age 21 and former foster youth up to age 26. This federal changes means the one year state law limit for Medi-Cal benefit suspension must be conformed to federal law this population

According to the Author:

Compared to other individuals in the community, these incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying for Medi-Cal is detrimental to an individual's health outcomes and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual's life after release.

Arguments in Support:

The California State Association of Counties (CSAC) and the County Welfare Directors Association (CWDA) write in support that this bill would allow county welfare departments to continue to suspend eligibility for Medi-Cal for incarcerated individuals past one year to avoid unnecessary workload and ensure that individuals are eligible for critical health and behavioral health services upon release. CWDA and CSAC write that current law requires counties to suspend Medi-Cal eligibility for individuals who become incarcerated for up to one year from the date of incarceration, or upon release, whichever comes sooner. This current limitation makes it more difficult for individuals who are incarcerated for longer periods of time to obtain Medi-Cal benefits prior to their release from jail or prison. Individuals who become incarcerated and have their Medi-Cal benefits suspended, then subsequently terminated based on the one year limit, are required to re-apply for benefits in order to restore their Medi-Cal eligibility. By indefinitely suspending Medi-Cal benefits, CSAC and CWDA write that this bill ensures that incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release, rather than requiring them to re-apply. This provides continuity in mental health care, physical treatment and prescription medication between the period of incarceration and reintegration into their community. Ensuring all incarcerated persons return home without gaps in health care improves community safety, protects public health and reduces the likelihood of recidivism by ensuring people with medical care needs have immediate access to critical health supports they need for benefits and potentially not have access to care immediately.

Arguments in Opposition:

The Department of Finance (DOF) writes in opposition, arguing this bill creates a potentially significant state reimbursable mandate. Additionally, DOF argues this bill is duplicative of existing services within state prisons, and the cost of this change is more appropriately considered alongside other policy changes in the budget process.

FISCAL COMMENTS:

According to the Senate Appropriations Committee:

1. Costs of $5.98 million ($2.99 million General Fund (GF), $2.99 million federal funds) in fiscal year 2019-20 for annual redetermination costs [$580,000 total funds (TF) ($290,000 GF)] and one-time system modification costs of $5.4 million TF ($2.7 million GF) for the Department of Health Care Services (DHCS).
2. $230,000 (General Fund) for the California Department of Corrections and Rehabilitation's (CDCR's) database systems modification costs to allow interface with DHCS. The information technology modifications would consist of CDCR's Transitional Case Management Program establishing a portal/communication system to track any changes made by DHCS. When an inmate arrives in a California state prison, who is currently receiving Medi-Cal benefits, their information is coded into CDCR's primary electronic database, the Strategic Offender Management System, and automatically shared with the DHCS via a sharing agreement that feeds into DHCS' Medi-Cal system and updates the participant's Medi-Cal/SSI status. Operationally, CDCR would incur an absorbable workload to monitor upon intake and screen Medi-Cal beneficiaries who were under 26 years of age at the time they became an inmate of a public institution.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Wicks, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ASSEMBLY FLOOR: 75-0-5

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, O'Donnell, Obernolte, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Wicks, Wood, Rendon

ABS, ABST OR NV: Boerner Horvath, Cooley, Eduardo Garcia, Muratsuchi, Weber

SENATE FLOOR: 40-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

UPDATED:

VERSION: August 30, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0002070

 THIRD READING  

Bill No: AB 914

Author: Holden (D)

Amended: 8/30/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 6/19/19

AYES: Pan, Stone, Lena Gonzalez, Grove, Hurtado, Leyva, Mitchell, Monning, Rubio

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/30/19

AYES: Portantino, Bates, Bradford, Durazo, Hill, Jones, Wieckowski

ASSEMBLY FLOOR: 75-0, 5/23/19 - See last page for vote

SUBJECT: Medi-Cal: inmates: eligibility

SOURCE: Author

DIGEST:

This bill requires, beginning October 1, 2020, Medi-Cal benefits for beneficiaries under 26 years of age who become inmates of a public institution to be suspended until the beneficiary is no longer an inmate or no longer otherwise eligible for Medi-Cal. Requires the Department of Health Care Services, in consultation with stakeholders, to develop and implement a simplified annual eligibility redetermination for those individuals.

ANALYSIS:

Existing federal law:

1. Requires states to suspend, rather than terminate, Medicaid services for a juvenile enrolled in Medicaid during the period when the juvenile is an inmate of a public institution. Requires states to conduct a Medicaid eligibility redetermination prior to when the eligible juvenile is released from the public institution. (42 USC 1396a)
2. Defines “juvenile” to mean an individual who is under 21 years of age; or, under 26 years of age, was under foster care at age 18, and enrolled in Medicaid while under foster care. (42 USC §1396a)

Existing state law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Requires DHCS to suspend the Medi-Cal benefits of an individual who is a Medi-Cal beneficiary and becomes an inmate of a public institution, in accordance with federal law. Requires the suspension of benefits to extend from the date the individual becomes an inmate until the date they are no longer an inmate, or one year from the date of incarceration, whichever is sooner. [WIC §14011.10]
3. Requires county welfare departments to notify DHCS that an individual on Medi-Cal in their county is or will become an inmate of a public institution, within 10 days of receiving that information. [WIC §14011.10]

This bill:

1. Requires DHCS, beginning October 1, 2020, to suspend Medi-Cal benefits for beneficiaries under 26 years of age, who become inmates of a public institution, until the beneficiary is no longer an inmate or no longer otherwise eligible for Medi-Cal, whichever is sooner.
2. Requires DHCS to consult with stakeholders, including the County Welfare Directors Association of California and others, to develop and implement a simplified annual eligibility redetermination for individuals under 26 years of age. Expresses the legislative intent for this provision to supplement, rather than supplant, any existing programs that assist individuals in enrolling in Medi-Cal.
3. Requires provisions of this bill that are in conflict, or do not comply, with federal law, to be inoperative.
4. Requires reimbursement to local agencies and school districts for costs mandated in this bill, as determined by the Commission on State Mandates and pursuant to existing law.

Comments

Author’s statement. According to the author, compared to other individuals in the community, incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying is detrimental to an individual’s health outcome and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual’s life after release

1. Suspension of Medi-Cal benefits for incarcerated individuals. Federal law generally prohibits incarcerated individuals from receiving Medicaid services. However, states can determine that an incarcerated person is eligible for Medicaid services but suspend them from receiving services, rather than terminate them from the program altogether. In 2018, Congress passed and the President signed HR 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which requires states to suspend Medicaid benefits for juveniles who are Medicaid beneficiaries and become incarcerated. HR 6 defines juveniles as either an individual who is under the age of 21 or who is under the age of 26 and a former foster youth.

Prior to HR 6, guidance issued by the Centers for Medicare & Medicaid Services (CMS) in 2016 encouraged states to consider suspending the Medicaid benefits of eligible incarcerated individuals, but deferred to states on the duration and applicability of that suspension. According to the CMS, suspension allows an incarcerated individual to retain Medi-Cal eligibility status, providing continuity of care and enabling the individual to immediately access Medi-Cal coverage upon release. Existing state law allows for the suspension of benefits, for individuals of any age, for up to one year of incarceration or until the individual is released, whichever is soon. For individuals who are incarcerated for more than one year, their Medi-Cal coverage is terminated, they are removed from the Medi-Cal database, and they are required to reapply for coverage.

1. Transitional Case Management Program (TCMP). Some jails, and all state prisons, provide varying degrees of assistance to help adult individuals apply for Medi-Cal prior to release. According to the California Department of Corrections and Rehabilitation (CDCR), the Division of Adult Parole Operation’s TCMP provides pre-release benefit assistance to all eligible inmates releasing to Parole or Post Release Community Supervision within 120 days of release from prison. CDCR contracts with the University of California, San Diego to provide TCMP benefits and maintains a data sharing agreement with DHCS to allow both departments to track and exchange data about the Medi-Cal application status for those served by the program. After submission of a new application, a new eligibility determination can take between 45 to 90 days. Individuals may be released with an application still pending or a written or verbal determination, along with a Benefit Identification Card, in some instances. However, TCMP does not include assistance in selecting a Medi-Cal managed care plan. Therefore, most individuals who are released with a fully processed application receive Medi-Cal fee-for-service until a managed care plan is chosen or assigned.

Based on information available to CDCR through TCMP, only a very small percentage of the application are known to be ineligible or denied for Medi-Cal (typically less than 1% of all applications). However, there are some applications for which confirmation of Medi-Cal eligibility was not provided to TCMP by either the counties or DHCS. It is likely that some portion of those were ultimately approved for Medi-Cal. CDCR notes a number of reasons why an inmate might not have submitted an application for Medi-Cal through TCMP, including:

1. Inmate has access to other health insurance post-release;
2. Inmate already is located in a community program and does not have access to TCMP services prior to release or is otherwise unavailable to receive TCMP services at the location they are finishing out their sentence;
3. Inmate may decline services due to having other holds post release (e.g., out-of-state transfer);
4. Changes in expected inmate release date may result in insufficient time for TCMP to connect with inmate and process an application; and,
5. Inmates not interested in receiving TCMP services can decline to participate in the TCMP program.

Related/Prior Legislation

SB 222 (Hernandez, 2017) would have extended the suspension of Medi-Cal benefits to end on the date the individual is no longer an inmate of a public institution or is no longer otherwise eligible for benefits under the Medi-Cal program. SB 222 was held on the Senate Appropriations Committee suspense file.

AB 720 (Skinner, Chapter 646, Statutes of 2013) required the board of supervisors in each county to designate an entity to assist certain jail inmates to apply for a health insurance affordability program, as defined. Prohibited county jail inmates who are currently enrolled in the Medi-Cal from being terminated from the program due to their detention, unless required by federal law or they become otherwise ineligible, as specified. Deleted the age restriction relating to the suspension of Medi-Cal benefits provided to inmates of the public institution.

SB 480 (Yee, 2013) would have deleted the age restriction relating to the suspension of Medi-Cal benefits provided to inmates of the public institution. SB 480 failed passage in the Senate Human Services Committee.

SB 1147 (Calderon, Chapter 546, Statutes of 2008) required DHCS to develop procedures to ensure that the Medi-Cal eligibility of minors is not terminated when they are incarcerated. Required Medi-Cal benefits provided to an individual under 21 years of age who is an inmate of a public institution to be suspended on the date the inmate is no longer incarcerated or one year from the date of incarceration, whichever is sooner.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee:

• $5.98 million ($2.99 million General Fund, $2.99 million federal funds) in FY 2019-20 for annual redetermination costs [$580,000 TF ($290,000 GF)] and one-time system modification costs of $5.4 million TF ($2.7 million GF) for the DHCS.
• $230,000 (General Fund) for CDCR’s database systems modification costs to allow interface with DHCS. The information technology modifications would consist of CDCR’s Transitional Case Management Program establishing a portal/communication system to track any changes made by DHCS.  When an inmate arrives in a California state prison, who is currently receiving Medi-Cal benefits, their information is coded into CDCR’s primary electronic database, the Strategic Offender Management System, and automatically shared with the DHCS via a sharing agreement that feeds into DHCS’ Medi-Cal system and updates the participant’s Medi-Cal/SSI status. Operationally, CDCR would incur an absorbable workload to monitor upon intake and screen Medi-Cal beneficiaries who were under 26 years of age at the time they became an inmate of a public institution.  

SUPPORT: (Verified 8/26/19)

California Pan-Ethnic Health Network

California State Association of Counties
California State Sheriffs' Association 
CaliforniaHealth+ Advocates

City and County of San Francisco

Community Clinic Association of Los Angeles County

County Behavioral Health Directors Association of California

County Welfare Directors Association of California

LA Care Health Plan

Root and Rebound

San Francisco Department of Public Health

Western Center of Law & Poverty

OPPOSITION: (Verified 8/26/19)

Department of Finance

ARGUMENTS IN SUPPORT: The California State Association of Counties (CSAC), the County Welfare Directors Association of California (CWDA), and the County Behavioral Health Directors Association of California(CBHDA) write in a joint letter in support of this bill. CSAC, CWDA, and CBHDA state that allowing county welfare departments to continue to suspend Medi-Cal eligibility for incarcerated indivdiuals under the age of 26 past one year avoids unnecessary workload and ensures individuals are eligible for critical health and behavioral health services upon release. LA Care Health Plan is also in support and writes that creating a streamlined process to redetermine a person’s eligibility on a yearly basis ensures incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release.

The San Francisco Department of Public Health (SFDPH), noting the significant health needs of incarcerated individuals, also supports this bill. SFPDH argues that interruptions in access to care following release increases an individual’s risk for substance use relapse, adverse health outcomes, and recidivism. The California Pan-Ethnic Health Network writes that for individuals with a mental illness or chemical dependency, an interruption in care can expose them to the conditions that originally led to their arrest. The California State Sheriffs’ Association, similarly, notes that providing individuals with medical treatment sooner upon release will reduce the chances of the individual recidivating.

ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) is opposed to this bill because it creates a potentially significant state reimbursable mandate. DOF also argues that this bill provides services that are duplicative of those that are provided within state prisons.

ASSEMBLY FLOOR: 75-0, 5/23/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Wicks, Wood, Rendon

NO VOTE RECORDED: Boerner Horvath, Cooley, Eduardo Garcia, Muratsuchi, Weber

Prepared by: Kimberly Chen / HEALTH / (916) 651-4111

9/3/19 11:05:18

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 914 (Holden) - Medi-Cal: inmates: eligibility

Bill Summary:

Assembly Bill 914 would require Medi-Cal benefits, for beneficiaries under 26 years of age who become inmates of a public institution, to be suspended until the beneficiary is no longer incarcerated or no longer otherwise eligible for Medi-Cal.  Would require the Department of Health Care Services (DHCS), in consultation with specified stakeholders, to develop and implement a simplified annual eligibility redetermination for specified individuals.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on August 30, 2019

Fiscal Impact:

Staff estimates:

• $5.98 million ($2.99 million General Fund, $2.99 million federal funds) in FY 2019-20 for annual redetermination costs [$580,000 TF ($290,000 GF)] and one-time system modification costs of $5.4 million TF ($2.7 million GF) for the DHCS.
• $230,000 (General Fund) for the Department of Corrections and Rehabilitation (CDCR)’s database systems modification costs to allow interface with DHCS. The IT modifications would consist of CDCR’s Transitional Case Management Program establishing a portal/communication system to track any changes made by DHCS.  When an inmate arrives in a California state prison, who is currently receiving Medi-Cal benefits, their information is coded into CDCR’s primary electronic database, the Strategic Offender Management System (SOMS), and automatically shared with the DHCS via a sharing agreement that feeds into DHCS’ Medi-Cal system and updates the participant’s Medi-Cal/SSI status. Operationally, CDCR would incur an absorbable workload to monitor upon intake and screen Medi-Cal beneficiaries who were under 26 years of age at the time they became an inmate of a public institution.  

Author Amendments:

The author’s amendments would include the following:

• Delays implementation until October 1, 2020, and,
• Makes severable the provisions that are noncompliant or in conflict with federal law.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 914 (Holden) - Medi-Cal: inmates: eligibility

Bill Summary:

Assembly Bill 914 would require Medi-Cal benefits, for beneficiaries under 26 years of age who become inmates of a public institution, to be suspended until the beneficiary is no longer incarcerated or no longer otherwise eligible for Medi-Cal.  Would require the Department of Health Care Services (DHCS), in consultation with specified stakeholders, to develop and implement a simplified annual eligibility redetermination for specified individuals.

Fiscal Impact:

• $5.98 million ($2.99 million General Fund, $2.99 million federal funds) in FY 2019-20 for annual redetermination costs [$580,000 TF ($290,000 GF)] and one-time system modification costs of $5.4 million TF ($2.7 million GF) for the DHCS.
• $230,000 (General Fund) for the Department of Corrections and Rehabilitation (CDCR)’s database systems modification costs to allow interface with DHCS. Currently, CDCR’s Transitional Case Management Program (TCMP) provides pre-release benefit assistance (Medi-Cal, Social Security, Veterans Administration) to all eligible inmates releasing to parole or post release community supervision approximately 90-120 days prior to release from prison. The IT modifications would consist of CDCR’s TCMP establishing a portal/communication system to track any changes made by DHCS.  When an inmate arrives in a California state prison, who is currently receiving Medi-Cal benefits, their information is coded into CDCR’s primary electronic database, the Strategic Offender Management System (SOMS), and automatically shared with the DHCS via a sharing agreement that feeds into DHCS’ Medi-Cal system and updates the participant’s Medi-Cal/SSI status. Operationally, CDCR would incur an absorbable workload to monitor upon intake and screen Medi-Cal beneficiaries who were under 26 years of age at the time they became an inmate of a public institution.  

Background:

1. In 2018, the President signed H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which requires states to suspend Medicaid benefits, rather than terminate, for Medicaid juvenile beneficiaries who become incarcerated. HR 6 defines juveniles as either an individual who is under the age of 21, or who is under the age of 26 and a former foster youth.

Existing state law requires DHCS to suspend the suspension of benefits, for individuals of any age, for up to one year of incarceration or until the individual is released, whichever is sooner (WIC §14011.10). For individuals who are incarcerated more than one year, their Medi-Cal coverage is terminated, and they are removed from the Medi-Cal database and must re-apply to the program.

Under federal regulations DHCS must re-determine the eligibility of a Medi-Cal beneficiary once every 12 months, and state law and regulations require counties to complete this annual redetermination process. The redetermination process includes a number of forms and requires the beneficiary to provide, within 20 days, information on changes in household circumstances and verification of income or property. If a beneficiary fails to complete the process and be re-determined eligible for Medi-Cal, the beneficiary will lose Medi-Cal coverage. Under current practice, when a county performs an annual eligibility redetermination, the county first attempts to verify continued eligibility using electronic sources (such as federal income information). If those existing data sources indicate that the individual is still eligible for Medi-Cal, then the county renews eligibility automatically.

Proposed Law:

AB 914 would, subject to federal approval, for individuals under 26 years of age, require the suspension of Medi-Cal eligibility to end either on the date that the individual is no longer an inmate of the public institution or is no longer otherwise eligible for benefits under the Medi-Cal program, whichever is sooner.

The bill would require DHCS, in consultation with specified stakeholders, to develop and implement a simplified annual redetermination of eligibility for individuals under 26 years of age whose eligibility is suspended pursuant to the bill’s provisions.

Related Legislation:

• SB 222 (Hernandez, 2017) would have extended the suspension of Medi-Cal benefits to end on the date the individual is no longer an inmate of a public institution or is no longer otherwise eligible for benefits under the Medi-Cal program. SB 222 was held on the Senate Appropriations Committee suspense file.
• AB 720 (Skinner, Chapter 646, Statutes of 2013) requires each county board of supervisors in each county to designate an entity to assist certain jail inmates to apply for a health insurance affordability program, as defined. Prohibits county jail inmates who are currently enrolled in the Medi-Cal from being terminated from the program due to their detention, unless required by federal law or they become otherwise ineligible, as specified. Deletes the age restriction relating to the suspension of Medi-Cal benefits provided to inmates of the public institution.

Staff Comments:

According to the Senate Health Committee analysis of this bill, the CDCR contracts with the University of California, San Diego to provide TCMP benefits and maintains a data-sharing agreement with DHCS to allow both departments to track and exchange data about the Medi-Cal application status for those served by the program. Below is an updated table for the first quarter of 2019:

Table 1. TCMP Medi-Cal Submissions and Timing of Approval Confirmation: Jan-Mar 2019

¹MC approval confirmations provided by Counties to TCMP prior to inmate release.

²MC approval confirmations provided by Counties to TCMP or via data match with DHCS after inmate release.

³Total confirmed MC approvals (by County information or via data match with DHCS).

There remain a variety of reasons why an inmate may not have submitted an application, including: access to other health insurance post-release; having other holds post-release (e.g., out-of-state transfer); changes in expected inmate release date; or an inmate is located in a community program and does not have access to TCMP services prior to release.

Staff notes the slight potential for increased Medi-Cal utilization, which could be offset in unknown, future healthcare system savings and reductions in recidivism, to the extent that individuals who were formerly incarcerated are connected to health services immediately upon release. In addition, CDCR’s recent data January – March 2019 data from CDCR, demonstrates 86 percent of were approve. Under the bill, those inmates would have Medi-Cal eligibility re-instated, rather than a new eligibility determination.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 914

SUBJECT: Medi-Cal: inmates: eligibility

SUMMARY:

Requires Medi-Cal benefits for beneficiaries under 26 years of age who become inmates of a public institution to be suspended until the beneficiary is no longer an inmate or no longer otherwise eligible for Medi-Cal. Requires the Department of Health Care Services to develop and implement a simplified annual eligibility redetermination for those individuals.

Existing federal law:

1. Requires states to suspend, rather than terminate, Medicaid services for a juvenile enrolled in Medicaid during the period when the juvenile is an inmate of a public institution. Requires states to conduct a Medicaid eligibility redetermination prior to when the eligible juvenile is released from the public institution. (42 USC 1396a)
2. Defines “juvenile” to mean an individual who is under 21 years of age; or, under 26 years of age, was under foster care at age 18, and enrolled in Medicaid while under foster care. (42 USC §1396a)

Existing state law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Requires DHCS to suspend the Medi-Cal benefits of an individual who is a Medi-Cal beneficiary and becomes an inmate of a public institution, in accordance with federal law. Requires the suspension of benefits to extend from the date the individual becomes an inmate until the date they are no longer an inmate, or one year from the date of incarceration, whichever is sooner. [WIC §14011.10]
3. Requires county welfare departments to notify DHCS that an individual on Medi-Cal in their county is or will become an inmate of a public institution, within 10 days of receiving that information. [WIC §14011.10]

This bill:

1. Requires DHCS to suspend Medi-Cal benefits for beneficiaries under 26 years of age, who become inmates of a public institution, until the beneficiary is no longer an inmate or no longer otherwise eligible for Medi-Cal, whichever is sooner.
2. Requires DHCS to consult with stakeholders, including the County Welfare Directors Association of California and others, to develop and implement a simplified annual eligibility redetermination for individuals under 26 years of age. Expresses the legislative intent for this provision to supplement, rather than supplant, any existing programs that assist individuals in enrolling in Medi-Cal.
3. Requires reimbursement to local agencies and school districts for costs mandated in this bill, as determined by the Commission on State Mandates and pursuant to existing law.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. Likely one-time costs in the hundreds of thousands to develop the simplified annual renewal process, seek federal approval and make any necessary system changes (General Fund (GF)/federal).
2. Projected annual costs in the hundreds of thousands to perform additional annual redeterminations (GF/federal). Under this bill, counties would continue to perform annual redeterminations for inmates (rather than dis-enrolling them after one year). There would be administrative costs to counties to perform the annual redeterminations after the first year of incarceration.
3. Minor potential increased Medi-Cal costs due to higher and more-immediate Medi-Cal enrollment under this bill than would otherwise occur (GF/federal).

PRIOR VOTES:

COMMENTS:

Author’s statement. According to the author, compared to other individuals in the community, incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying is detrimental to an individual’s health outcome and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual’s life after release

1. Suspension of Medi-Cal benefits for incarcerated individuals. Federal law generally prohibits incarcerated individuals from receiving Medicaid services. However, states can determine that an incarcerated person is eligible for Medicaid services but suspend them from receiving services, rather than terminate them from the program altogether. In 2018, Congress passed and the President signed HR 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which requires states to suspend Medicaid benefits for juveniles who are Medicaid beneficiaries and become incarcerated. HR 6 defines juveniles as either an individual who is under the age of 21 or who is under the age of 26 and a former foster youth.

Prior to HR 6, guidance issued by the Centers for Medicare & Medicaid Services (CMS) in 2016 encouraged states to consider suspending the Medicaid benefits of eligible incarcerated individuals, but deferred to states on the duration and applicability of that suspension. According to the CMS, suspension allows an incarcerated individual to retain Medi-Cal eligibility status, providing continuity of care and enabling the individual to immediately access Medi-Cal coverage upon release. Existing state law allows for the suspension of benefits, for individuals of any age, for up to one year of incarceration or until the individual is released, whichever is soon. For individuals who are incarcerated for more than one year, their Medi-Cal coverage is terminated, they are removed from the Medi-Cal database, and they are required to reapply for coverage.

1. Transitional Case Management Program (TCMP). Some jails, and all state prisons, provide varying degrees of assistance to help adult individuals apply for Medi-Cal prior to release. According to California Department of Corrections and Rehabilitation (CDCR), the Division of Adult Parole Operation’s TCMP provides pre-release benefit assistance to all eligible inmates releasing to Parole or Post Release Community Supervision within 120 days of release from prison. CDCR contracts with the University of California, San Diego to provide TCMP benefits and maintains a data sharing agreement with DHCS to allow both departments to track and exchange data about the Medi-Cal application status for those served by the program. After submission of a new application, a new eligibility determination can take between 45 to 90 days. Individuals may be released with an application still pending or a written or verbal determination, along with a Benefit Identification Card, in some instances. However, TCMP does not include assistance in selecting a Medi-Cal managed care plan. Therefore, most individuals who are released with a fully processed application receive Medi-Cal fee-for-service until a managed care plan is chosen or assigned.

Based on information available to CDCR through TCMP, only a very small percentage of the application are known to be ineligible or denied for Medi-Cal (typically less than 1% of all applications). However, there are some applications for which confirmation of Medi-Cal eligibility was not provided to TCMP by either the counties or DHCS. It is likely that some portion of those were ultimately approved for Medi-Cal. Below is a table that details the applications approved and confirmed by TCMP in 2018:

Table 1. TCMP Medi-Cal Submissions and Timing of Approval Confirmation: 2018

CDCR notes a number of reasons why an inmate might not have submitted an application for Medi-Cal through TCMP, including:

1. Inmate has access to other health insurance post-release;
2. Inmate already is located in a community program and does not have access to TCMP services prior to release or is otherwise unavailable to receive TCMP services at the location they are finishing out their sentence;
3. Inmate may decline services due to having other holds post release (e.g., out-of-state transfer);
4. Changes in expected inmate release date may result in insufficient time for TCMP to connect with inmate and process an application; and,
5. Inmates not interested in receiving TCMP services can decline to participate in the TCMP program.
6. Medi-Cal annual redetermination. Federal regulations require DHCS to redetermine the eligibility of a Medi-Cal beneficiary once every 12 months. State law and regulations require counties to complete this annual redetermination process. During the process, counties are required to mail the beneficiary a redetermination package, which includes a number of forms and requires the beneficiary to provide, within 20 days, information on changes in household circumstances and verification of income or property. The beneficiary does not need to provide information that is not subject to change, such as their birth date. If a beneficiary fails to complete the process and be redetermined eligible for Medi-Cal, the beneficiary will lose Medi-Cal coverage.
7. Prior legislation. SB 222 (Hernandez of 2017) would have extended the suspension of Medi-Cal benefits to end on the date the individual is no longer an inmate of a public institution or is no longer otherwise eligible for benefits under the Medi-Cal program. SB 222 was held on the Senate Appropriations Committee suspense file.

AB 720 (Skinner, Chapter 646, Statutes of 2013) requires the board of supervisors in each county to designate an entity to assist certain jail inmates to apply for a health insurance affordability program, as defined. Prohibits county jail inmates who are currently enrolled in the Medi-Cal from being terminated from the program due to their detention, unless required by federal law or they become otherwise ineligible, as specified. Deletes the age restriction relating to the suspension of Medi-Cal benefits provided to inmates of the public institution.

SB 480 (Yee of 2013) would have deleted the age restriction relating to the suspension of Medi-Cal benefits provided to inmates of the public institution. SB 480 failed passage in the Senate Committee on Human Services.

SB 1147 (Calderon, Chapter 546, Statutes of 2008) requires DHCS to develop procedures to ensure that the Medi-Cal eligibility of minors is not terminated when they are incarcerated. Requires Medi-Cal benefits provided to an individual under 21 years of age who is an inmate of a public institution to be suspended on the date the inmate is no longer incarcerated or one year from the date of incarceration, whichever is sooner.

1. Support. The California State Association of Counties (CSAC), the County Welfare Directors Association of California (CWDA), and the County Behavioral Health Directors Association of California(CBHDA) write in a joint letter in support of this bill. CSAC, CWDA, and CBHDA state that allowing county welfare departments to continue to suspend Medi-Cal eligibility for incarcerated indivdiuals under the age of 26 past one year avoids unnecessary workload and ensures individuals are eligible for critical health and behavioral health services upon release. LA Care Health Plan is also in support and writes that creating a streamlined process to redetermine a person’s eligibility on a yearly basis ensures incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release.

The San Francisco Department of Public Health (SFDPH), noting the significant health needs of incarcerated individuals, also supports this bill. SFPDH argues that interruptions in access to care following release increases an individual’s risk for substance use relapse, adverse health outcomes, and recidivism. The California Pan-Ethnic Health Network writes that for individuals with a mental illness or chemical dependency, an interruption in care can expose them to the conditions that originally led to their arrest. The California State Sheriffs’ Association, similarly, notes that providing individuals with medical treatment sooner upon release will reduce the chances of the individual recidivating.

1. Policy comment. Changes in federal law mandated by HR 6 now require the suspension of Medicaid benefits until a juvenile is released or until they are no longer eligible for benefits. It defines juveniles as individuals under the age of 21 or former foster youth under the age of 26. Medi-Cal currently provides coverage for former foster youth who are under the age of 26. Existing state law is out of compliance and should be amended to conform to the new federal requirements. This bill would go above the federal mandate, requiring the suspension of benefits to apply all individuals under the age of 26, which would cover non-former foster youth individuals between the ages of 21 and 25, inclusive.

SUPPORT AND OPPOSITION:

Support: California Pan-Ethnic Health Network

California State Association of Counties
California State Sheriffs' Association 
CaliforniaHealth+ Advocates

City and County of San Francisco

Community Clinic Association of Los Angeles County

County Behavioral Health Directors Association of California

County Welfare Directors Association of California

LA Care Health Plan

Root and Rebound

San Francisco Department of Public Health

Western Center of Law & Poverty

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 914

Author:(Holden)

As Amended Ver:May 16, 2019

Majority vote

SUMMARY:

Extends the duration during which Medi-Cal benefits are suspended when an individual under age 26 is an inmate of a public institution until the individual is no longer an inmate or is no longer eligible, whichever occurs sooner, instead of the existing time-limited suspension of benefits under existing law of one year from the date the person became an inmate or one year or until the individual is no longer eligible, whichever occurs sooner. Requires the Department of Health Care Services to develop and implement a simplified annual redetermination of eligibility for individuals under age 26 whose eligibility is suspended.

Major Provisions

COMMENTS:

BACKGROUND. Existing federal law prevents Medicaid benefits from being paid for incarcerated individuals except when the inmate is a patient in a medical institution. While incarceration generally excludes inmates from Medicaid payments (except for inpatient services provided outside the prison), federal law does not make them ineligible for Medicaid. The Centers for Medicare and Medicaid Services (CMS) published a letter of guidance in 2016 stating that incarceration does not preclude an inmate from being determined Medicaid eligible. In addition, to promote continuity of care, CMS encouraged states to place the inmate in suspended eligibility status during the period of incarceration, or to implement a claims processing provision to ensure that services are limited to only inpatient services. Suspension of Medi-Cal coverage is effective the date an individual becomes an inmate of a public institution, allowing an inmate to retain eligibility status for Medi-Cal but prohibiting receipt of benefits during incarceration. Termination removes an individual from the state's Medi-Cal database and requires submission of a new application after release from jail or prison.

HR 6 aND Medi-Cal for incarcerated persons. Under current state law, Medi-Cal beneficiaries who become incarcerated have their benefits suspended for one year or until they are released, whichever comes first. For those incarcerated for less than one year, coverage is reinstated by Department of Health Care Services upon release. Anyone over the age of 18 who is incarcerated for longer than one year has their Medi-Cal coverage terminated. Due to recent changes in federal law made in 2018 by HR 6 (Public Law 115-271), known as the "Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act," juveniles who are inmates of public institutions can no longer have a time-limited suspension of Medicaid. HR 6 defined "juveniles" as individuals under to age 21 and former foster youth up to age 26. This federal changes means the one year state law limit for Medi-Cal benefit suspension must be conformed to federal law this population.

According to the Author:

Compared to other individuals in the community, these incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying for Medi-Cal is detrimental to an individual's health outcomes and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual's life after release.

Arguments in Support:

The California State Association of Counties (CSAC) and the County Welfare Directors Association (CWDA) write in support that this bill would allow county welfare departments to continue to suspend eligibility for Medi-Cal for incarcerated individuals past one year to avoid unnecessary workload and ensure that individuals are eligible for critical health and behavioral health services upon release. CWDA and CSAC write that current law requires counties to suspend Medi-Cal eligibility for individuals who become incarcerated for up to one year from the date of incarceration, or upon release, whichever comes sooner. This current limitation makes it more difficult for individuals who are incarcerated for longer periods of time to obtain Medi-Cal benefits prior to their release from jail or prison. Individuals who become incarcerated and have their Medi-Cal benefits suspended, then subsequently terminated based on the one year limit, are required to re-apply for benefits in order to restore their Medi-Cal eligibility. By indefinitely suspending Medi-Cal benefits, CSAC and CWDA write that this bill ensures that incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release, rather than requiring them to re-apply. This provides continuity in mental health care, physical treatment and prescription medication between the period of incarceration and reintegration into their community. Ensuring all incarcerated persons return home without gaps in health care improves community safety, protects public health and reduces the likelihood of recidivism by ensuring people with medical care needs have immediate access to critical health supports they need for benefits and potentially not have access to care immediately.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Likely one-time costs in the hundreds of thousands to develop the simplified annual renewal process, seek federal approval and make any necessary system changes (General Fund (GF)/federal).
2. Projected annual costs in the hundreds of thousands to perform additional annual redeterminations (GF/federal). Under the bill, counties would continue to perform annual redeterminations for inmates (rather than disenrolling them after one year). There would be administrative costs to counties to perform the annual redeterminations after the first year of incarceration.
3. Minor potential increased Medi-Cal costs due to higher and more-immediate Medi-Cal enrollment under the bill than would otherwise occur (GF/federal).

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Wicks, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: May 16, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0000836

Date of Hearing: May 16, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 914

Author:(Holden) – As Amended Ver:March 18, 2019

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill extends Medi-Cal eligibility for an individual who is an inmate of a public institution until the individual is no longer an inmate or no longer eligible, whichever occurs sooner.

FISCAL EFFECT:

1. Likely one-time costs in the hundreds of thousands to develop the simplified annual renewal process, seek federal approval and make any necessary system changes (GF/federal).
2. Projected annual costs in the low millions of dollars to perform additional annual redeterminations that would otherwise not occur (GF/federal). Under the bill, counties would continue to perform annual redeterminations for inmates (rather than disenrolling them after one year). There would be administrative costs to counties to perform the annual redeterminations after the first year of incarceration.
3. Minor potential increased Medi-Cal costs due to higher and more-immediate Medi-Cal enrollment under the bill than would otherwise occur (GF/federal).

COMMENTS:

1. Purpose. According to the author, compared to other individuals in the community, incarcerated individuals are more likely to have chronic physical and mental conditions. The author contends the lengthy process of terminating and reapplying for Medi-Cal is detrimental to an individual’s health outcomes and this bill suspends but preserves Medi-Cal eligibility so individuals need not reapply for coverage.
2. Background. Existing federal law prevents Medicaid benefits from being paid for incarcerated individual except when the inmate is a patient in a medical institution. While an incarceration generally excludes inmates from Medicaid payments (except for inpatient services provided outside the prison), federal law does not make them ineligible for Medicaid.

Current state law specifies existing time-limited suspension of benefits of one year from the date the person became an inmate or one year or until the individual is no longer eligible, whichever occurs sooner. The federal Centers for Medicare and Medicaid Services (CMS) published a letter of guidance in 2016 stating incarceration does not preclude an inmate from being determined Medicaid-eligible. In addition, to promote continuity of care, CMS encouraged states to place the inmate in suspended eligibility status during the period of incarceration or to implement a claims processing provision to ensure services are limited to only inpatient services.

A 2018 federal law change has also prohibited imposing a time-limited suspension of Medicaid on juveniles who are inmates of public institutions. This bill would make such a change for all populations.

1. Support. The California State Association of Counties (CSAC) and the County Welfare Directors Association (CWDA) write in support that this bill would allow county welfare departments to continue to suspend eligibility for Medi-Cal for incarcerated individuals past one year to avoid unnecessary workload and ensure individuals are eligible for critical health and behavioral health services upon release.
2. Prior Legislation. SB 222 (Hernández), of the 2017-18 Legislative Session, was similar to this bill and would have required DHCS to extend the suspension of Medi-Cal benefits of incarcerated persons from one year to the entire duration of the persons incarceration. SB 222 was held on the Suspense File of the Senate Appropriations Committee.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 9, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 914

Author:(Holden) – As Amended Ver:March 18, 2019

SUBJECT: Medi-Cal: inmates: eligibility.

SUMMARY: Extends the duration during which Medi-Cal benefits are suspended when an individual is an inmate of a public institution until the individual is no longer an inmate or is no longer eligible, whichever occurs sooner, instead of the existing time-limited suspension of benefits of one year from the date the person became an inmate or one year or until the individual is no longer eligible, whichever occurs sooner. Specifically, this bill:

1. Requires, if an individual is a Medi-Cal beneficiary on the date they become an inmate of a public institution, their Medi-Cal benefits to be suspended effective the date they become an inmate of a public institution until the sooner of the following:
   
   1. The end of the date they are no longer an inmate of a public institution (instead of one year from the date they became an inmate); or,
   2. Until the individual is no longer eligible for benefits under the Medi-Cal program.
      
2. Requires the Department of Health Care Services (DHCS), in consultation with stakeholders, including the County Welfare Directors Association and advocates, to develop and implement a simplified annual redetermination of eligibility for individuals whose eligibility is suspended under this bill.

EXISTING LAW:

1. Requires Medi-Cal benefits provided to an individual who is an inmate of a public institution to be suspended in accordance with a specified provision of federal Medicaid law.
   
2. Requires, if an individual is a Medi-Cal beneficiary on the date they become an inmate of a public institution, his or her Medi-Cal benefits to be suspended effective the date he or she becomes an inmate of a public institution.
   
3. Requires the suspension to end on the date he or she is no longer an inmate of a public institution or one year from the date he or she becomes an inmate of a public institution.
   
4. Requires county welfare departments to notify DHCS within 10 days of receiving information that an individual on Medi-Cal in the county is or will be an inmate of a public institution.
   
5. Require counties to perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months, and to promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstances that may affect eligibility for Medi-Cal benefits.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, compared to other individuals in the community, these incarcerated individuals are more likely to have chronic physical and mental conditions. The lengthy process of terminating and reapplying for Medi-Cal is detrimental to an individual’s health outcomes and opportunities for successful reintegration. Studies have shown that continuity of care is critical in improving health outcomes, reducing demand for costly health care services later on, and improving recidivism rates. Suspending benefits and using a simplified form for yearly redetermination will make the transition out of incarceration seamless and improve an individual’s life after release.
2. BACKGROUND. Existing federal law prevents Medicaid benefits from being paid for incarcerated individuals except when the inmate is a patient in a medical institution. While incarceration generally excludes inmates from Medicaid payments (except for inpatient services provided outside the prison), federal law does not make them ineligible for Medicaid. The Centers for Medicare and Medicaid Services (CMS) published a letter of guidance in 2016 stating that incarceration does not preclude an inmate from being determined Medicaid eligible. In addition, to promote continuity of care, CMS encouraged states to place the inmate in suspended eligibility status during the period of incarceration, or to implement a claims processing provision to ensure that services are limited to only inpatient services.
3. HR 6 aND Medi-Cal for incarcerated persons. Under current state law, Medi-Cal beneficiaries who become incarcerated have their benefits suspended for one year or until they are released, whichever comes first. For those incarcerated for less than one year, coverage is reinstated by DHCS upon release. Anyone over the age of 18 who is incarcerated for longer than one year has their Medi-Cal coverage terminated. Due to recent changes in federal law made in 2018 by HR 6 (Public Law 115-271), known as the “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act,” juveniles who are inmates of public institutions can no longer have a time-limited suspension of Medicaid. HR 6 defined “juveniles” as individuals under to age 21 and former foster youth up to age 26. This federal changes means the one year state law limit for Medi-Cal benefit suspension must be conformed to federal law this population.
   
4. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION PROCESS. Individuals who lose coverage due to longer-term incarceration need to reapply for coverage. Some jails, and all state prisons, provide varying degrees of assistance to help individuals apply for Medi-Cal prior to release.
   
   The California Department of Corrections and Rehabilitation (CDCR) assists individuals with Medi-Cal applications prior to release. CDCR’s Division of Adult Parole Operations (DAPO) has a contract with the University of California San Diego to provide Transitional Case Management Program (TCMP) benefits assistance to inmates who will be released to parole or post-release community supervision (PRCS) within 120 days.
   
   TCMP provides inmates with pre-release Medi-Cal, Social Security Administration (SSA), and Veterans Administration (VA) benefit application assistance. TCMP also provides community referral to long term community case manager/health care providers for inmates diagnosed with HIV/AIDS. CDCR has an agreement with the SSA, DHCS and the VA to provide pre-release benefit assistance to all eligible inmates releasing to PRCS. The chart below for the 2018 calendar years shows total inmate releases and how many and what percentage of those individuals were enrolled in Medi-Cal pre-release and after release.

Table 1. TCMP Medi-Cal Submissions and Timing of Approval Confirmation: 2018

¹MC approval confirmations provided by Counties to TCMP prior to inmate release.

²MC approval confirmations provided by Counties to TCMP or via data match with DHCS after inmate release.

³Total confirmed MC approvals (by County information or via data match with DHCS).

CDCR indicates there are a variety of reasons why an inmate may not have a Medi-Cal application submitted through the TCMP. CDCR indicates the most common reasons are:

1. The inmate has access to other health insurance post-release;
2. The inmate already is located in a community program and does not have access to TCMP services prior to release or is otherwise unavailable to receive TCMP services at the location they are finishing out their sentence;
3. The inmate declines services due to having other holds post release (e.g., out-of-state transfer);
4. Changes in the expected inmate release date may result in insufficient time for TCMP to connect with inmate and process an application; and,
5. The inmate is not interested in receiving TCMP services and can decline to participate in the TCMP program.
   

CDCR indicates that, based on the information available to TCMP regarding Medi-Cal application outcomes, only a very small percentage of the applicants are known to be ineligible/denied for Medi-Cal (CDCR estimates typically less than 1% of applications), but there are some applications (typically about 12-14%), for which confirmation of Medi-Cal eligibility was not provided to TCMP by either the counties or DHCS. CDCR states it is likely that some portion of these inmates ultimately were approved for Medi-Cal, but the exact numbers are unknown.

1. Suspension versus termination. Suspension of Medi-Cal coverage is effective the date an individual becomes an inmate of a public institution, allowing an inmate to retain eligibility status for Medi-Cal but prohibiting receipt of benefits during incarceration. Termination removes an individual from the state’s Medi-Cal database and requires submission of a new application after release from jail or prison. According to the National Association of Counties, terminating benefits prior to release, rather than leaving individuals in a suspended status, increases the gap in health care services, which are critical in the first weeks and months post-incarceration. The Kaiser Family Foundation released a report stating that improved access to services and better management of health conditions immediately after release from jail or prison has shown to reduce rates of recidivism, particularly among individuals with mental health and substance abuse disorders. Studies published by the American Psychiatric Association show that inmates who were enrolled in Medicaid at the time of release had 16% fewer incidents of recidivism compared to those not enrolled at the time of release.
2. Other states. According to FamiliesUSA, as of June 2016, 17 states including Washington, D.C. suspend Medicaid for the entire duration of incarceration; 15 states suspend Medicaid for a specific amount of time, ranging from 30 days to one year; and 19 states terminate Medicaid coverage as soon as a person enters a public institution. Most recently, Hawaii and Washington have passed legislation to move from termination or limited suspension to extended suspension until release.
3. SUPPORT. The California State Association of Counties (CSAC) and the County Welfare Directors Association (CWDA) write in support that this bill would allow county welfare departments to continue to suspend eligibility for Medi-Cal for incarcerated individuals past one year to avoid unnecessary workload and ensure that individuals are eligible for critical health and behavioral health services upon release. CWDA and CSAC write that current law requires counties to suspend Medi-Cal eligibility for individuals who become incarcerated for up to one year from the date of incarceration, or upon release, whichever comes sooner. This current limitation makes it more difficult for individuals who are incarcerated for longer periods of time to obtain Medi-Cal benefits prior to their release from jail or prison. Individuals who become incarcerated and have their Medi-Cal benefits suspended, then subsequently terminated based on the one year limit, are required to re-apply for benefits in order to restore their Medi-Cal eligibility. Per federal guidance, this one year time limit is not mandated and states are directed to leave individuals in a suspension status until they are no longer eligible for benefits, or upon release, whichever occurs first.
   
   By indefinitely suspending Medi-Cal benefits, CSAC and CWDA write that this bill ensures that incarcerated individuals have immediate access to benefits that are essential for their basic needs upon release, rather than requiring them to re-apply. This provides continuity in mental health care, physical treatment and prescription medication between the period of incarceration and reintegration into their community. Ensuring all incarcerated persons return home without gaps in health care improves community safety, protects public health and reduces the likelihood of recidivism by ensuring people with medical care needs have immediate access to critical health supports they need for benefits and potentially not have access to care immediately.

Western Center on Law & Poverty writes in support that studies show that incarcerated people in all gender, race, and ethnicity groups earned substantially less prior to their incarceration than their non-incarcerated counterparts of similar ages. When these individuals are released, they face employer discrimination in addition to the poverty they already experienced before their incarceration. Eliminating their Medi-Cal benefits adds an additional, and unnecessary, barrier to a successful re-entry and perpetuates the link between poverty and encounters with the criminal justice system. Studies of suspension of Medicaid coverage for justice involved individuals implemented in Florida and Washington found those enrolled in Medicaid at the time of release had 16% fewer incidents of recidivism compared to those not enrolled at the time of release.

1. PREVIOUS LEGISLATION. SB 222 (Hernandez) of 2017 would have required the suspension of Medi-Cal benefits to end on the date he or she is no longer an inmate of a public institution or is no longer otherwise eligible for benefits under the Medi-Cal program, instead of existing law, which requires the suspension to end on the date that the individual is no longer an inmate of a public institution or one year from the date he or she becomes an inmate of a public institution, whichever is sooner. SB 222 was held on the Senate Appropriations Committee suspense file.

SB 1147 (Calderon), Chapter 546, Statutes of 2008, requires DHCS to develop procedures to ensure that the Medi-Cal eligibility of minors is not terminated when they are incarcerated. Requires Medi-Cal benefits provided to an individual under 21 years of age who is an inmate of a public institution (a state or federal prison, correctional facility, county/city jail, or detention center) to be suspended in accordance with provisions of federal law.

AB 720 (Skinner), Chapter 646, Statutes of 2013, requires the board of supervisors in each county to designate an entity to assist certain jail inmates to apply for a health insurance affordability program, as defined. Prohibits county jail inmates who are currently enrolled in the Medi-Cal from being terminated from the program due to their detention, unless required by federal law or they become otherwise ineligible, as specified. Deletes the age restriction relating to Medi-Cal benefits provided to inmates of the public institution.

SB 480 (Yee) of 2014, would have required DHCS to suspend Medi-Cal benefits for inmates over the age of twenty one for the duration of his or her stay in a public institution or one year, whichever is less. SB 480 died in Senate Committee on Human Services.

1. POLICY ISSUE: Due to the change in federal law made by HR 6, the time-limited suspension of Medi-Cal eligibility for juveniles in state law needs to be changed. For adults, there is a contention among some advocates that any time-limited suspension of eligibility is illegal under federal Medicaid law.
   
   CDCR currently assists people in applying for enrollment in Medi-Cal upon release. In 2018, this resulted in nearly 80% of individuals applying for Medi-Cal. Of the individuals who applied, 87% were enrolled either pre-release or were confirmed to enroll after release. If the state suspends Medi-Cal during the duration of an adult’s prison sentence, federal law requires annual Medi-Cal eligibility determinations. While this bill requires DHCS to develop and implement a simplified annual redetermination of eligibility for individuals whose eligibility is suspended under this bill, DHCS does not separately budget for county Medi-Cal eligibility redetermination costs based on the status of the individual (this bill calls for the establishment of a simplified redetermination process for inmates). An indefinite suspension of adult Medi-Cal eligibility will impose administrative costs on the counties to perform annual redeterminations. Because the state pays counties to administer eligibility determinations for Medi-Cal, those costs would ultimately be borne by the state and federal government under Medi-Cal. CDCR currently assists incarcerated individuals leavings its facilities with enrolling in benefits programs, including Medi-Cal. CDCR data indicates nearly 80% of inmates apply for Medi-Cal now, and 87% of those applying are successfully enrolled upon release or immediately after release. The fiscal and policy issue posed by an indefinite suspension for adults is whether the cost of requiring counties to perform annual redeterminations is worth incurring versus the cost to CDCR of assisting with the completion of a new Medi-Cal application as part of a larger effort to enroll individuals into benefits and CDCR’s current Medi-Cal enrollment outcomes.

REGISTERED SUPPORT / OPPOSITION:

Support

California State Association of Counties
Community Clinic Association of Los Angeles County
LA Care Health Plan
Western Center on Law & Poverty, Inc.

Opposition

None on file.

Analysis Prepared by: Scott Bain / HEALTH / (916) 319-2097