AB 2956: Medi-Cal eligibility: redetermination.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2024-04-18
Current Status:
Failed
(2024-05-16: Joint Rule 62(a), file notice suspended. (Page 5215.))
Introduced
In Committee
First Chamber
In Committee
Second Chamber
Enacted
Existing law establishes 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 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 Medi-Cal eligibility. Existing law conditions implementation of the redetermination provisions on the availability of federal financial participation and receipt of any necessary federal approvals. Under existing law, if a county has facts clearly demonstrating that a Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an event, such as death or change of state residency, Medi-Cal benefits are terminated without a redetermination.
Existing law requires the department, subject to federal funding, to extend continuous eligibility to children 19 years of age or younger for a 12-month period, as specified. Under existing law, operative on January 1, 2025, or the date that the department certifies that certain conditions have been met, a child is continuously eligible for Medi-Cal up to 5 years of age. Under those provisions, a redetermination is prohibited during this time, unless certain circumstances apply, including, voluntary disenrollment, death, or change of state residency.
This bill would require the department to seek federal approval to extend continuous eligibility to individuals over 19 years of age. Under the bill, subject to federal funding, and except as described above with regard to death, change of state residency, or other events, an individual would remain eligible from the date of a Medi-Cal eligibility determination until the end of a 12-month period, as specified.
The bill would make various changes to the above-described redetermination procedures. The bill would, among other things, require the county, in the event of a loss of contact, to attempt communication with the intended recipient through all additionally available channels before completing a prompt redetermination. The bill would require the county to make another review of certain obtained information in an attempt to renew eligibility without needing a response from a beneficiary.
The bill would require the county to complete a determination at renewal without requesting additional information or documentation if specified conditions are met, relating to, among other things, prior income verification and no contradictory information on file.
When income is found not reasonably compatible from electronically available sources, the bill would require the county to first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. For purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, the bill would require a county to accept self-attested information, as specified.
Under the bill, for a beneficiary whose eligibility was discontinued due to failure to provide needed information and who submits to the county that information, as specified, the beneficiary would be entitled to a Medi-Cal eligibility determination for the 3 months immediately prior to the month in which the beneficiary provided the information, unless the beneficiary opts out. The bill would make conforming changes to related provisions.
In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population, as defined, makes contact with the county, the bill would require the county to begin a new 12-month eligibility period if certain conditions are met.
The bill would require the department to set a goal, in the form of a target rate of at least 50%, for successful ex parte renewals, and to post a related report. The bill would require counties to collect and submit to the department call-center data metrics.
The bill would require the department to seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described above, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
By creating new duties for counties relating to the redetermination of Medi-Cal eligibility, 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.
Existing law establishes 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 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 Medi-Cal eligibility. Existing law conditions implementation of the redetermination provisions on the availability of federal financial participation and receipt of any necessary federal approvals. Under existing law, if a county has facts clearly demonstrating that a Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an event, such as death or change of state residency, Medi-Cal benefits are terminated without a redetermination.
Existing law requires the department, subject to federal funding, to extend continuous eligibility to children 19 years of age or younger for a 12-month period, as specified. Under existing law, operative on January 1, 2025, or the date that the department certifies that certain conditions have been met, a child is continuously eligible for Medi-Cal up to 5 years of age. Under those provisions, a redetermination is prohibited during this time, unless certain circumstances apply, including, voluntary disenrollment, death, or change of state residency.
This bill would require the department to seek federal approval to extend continuous eligibility to individuals over 19 years of age. Under the bill, subject to federal funding, and except as described above with regard to death, change of state residency, or other events, an individual would remain eligible from the date of a Medi-Cal eligibility determination until the end of a 12-month period, as specified.
The bill would make various changes to the above-described redetermination procedures. The bill would, among other things, require the county, in the event of a loss of contact, to attempt communication with the intended recipient through all additionally available channels before completing a prompt redetermination. The bill would require the county to make another review of certain obtained information in an attempt to renew eligibility without needing a response from a beneficiary.
The bill would require the county to complete a determination at renewal without requesting additional information or documentation if specified conditions are met, relating to, among other things, prior income verification and no contradictory information on file.
When income is found not reasonably compatible from electronically available sources, the bill would require the county to first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. The bill would require the county to accept self-attestation of income in cases that meet certain conditions. For purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, the bill would require a county to accept self-attested information, as specified.
Under the bill, for a beneficiary whose eligibility was discontinued due to failure to provide needed information and who submits to the county that information, as specified, the beneficiary would be entitled to a Medi-Cal eligibility determination for the 3 months immediately prior to the month in which the beneficiary provided the information, unless the beneficiary opts out. The bill would make conforming changes to related provisions.
In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population, as defined, makes contact with the county, the bill would require the county to begin a new 12-month eligibility period if certain conditions are met.
The bill would require the department to set a goal, in the form of a target rate of at least 50%, for successful ex parte renewals, and to post a related report. The bill would require counties to collect and submit to the department call-center data metrics, and would require the department to post a related report on a quarterly basis. metrics.
The bill would require the department to seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described above, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
By creating new duties for counties relating to the redetermination of Medi-Cal eligibility, 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.
Existing law establishes 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 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 Medi-Cal eligibility. Existing law conditions implementation of the redetermination provisions on the availability of federal financial participation and receipt of any necessary federal approvals. Under existing law, if a county has facts clearly demonstrating that a Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an event, such as death or change of state residency, Medi-Cal benefits are terminated without a redetermination.
Existing law requires the department, subject to federal funding, to extend continuous eligibility to children 19 years of age or younger for a 12-month period, as specified. Under existing law, operative on January 1, 2025, or the date that the department certifies that certain conditions have been met, a child is continuously eligible for Medi-Cal up to 5 years of age. Under those provisions, a redetermination is prohibited during this time, unless certain circumstances apply, including, voluntary disenrollment, death, or change of state residency.
This bill would require the department to seek federal approval to extend continuous eligibility to individuals over 19 years of age. Under the bill, subject to federal funding, and except as described above with regard to death, change of state residency, or other events, an individual would remain eligible from the date of a Medi-Cal eligibility determination until the end of a 12-month period, as specified.
The bill would make various changes to the above-described redetermination procedures. The bill would, among other things, require the county, in the event of a loss of contact, to attempt communication with the intended recipient through all additionally available channels before completing a redetermination. The bill would require the county to make another review of certain obtained information in an attempt to renew eligibility without needing a response from a beneficiary.
The bill would require the county to complete a determination at renewal without requesting additional information or documentation if specified conditions are met, relating to, among other things, prior income verification and no contradictory information on file.
When income is found not reasonably compatible from electronically available sources, the bill would require the county to first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. The bill would require the county to accept self-attestation of income in cases that meet certain conditions.
Under the bill, for a beneficiary whose eligibility was discontinued due to failure to provide needed information and who submits to the county that information, as specified, the beneficiary would be entitled to a Medi-Cal eligibility determination for the 3 months immediately prior to the month in which the beneficiary provided the information, unless the beneficiary opts out.
In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population, as defined, makes contact with the county, the bill would require the county to begin a new 12-month eligibility period if certain conditions are met.
The bill would require the department to set a goal, in the form of a target rate of at least 50%, for successful ex parte renewals, and to post a related report. The bill would require counties to collect and submit to the department call-center data metrics, and would require the department to post a related report on a quarterly basis.
The bill would require the department to seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described above, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
By creating new duties for counties relating to the redetermination of Medi-Cal eligibility, 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.
(a)(1)An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
(2)For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.
(b)(1)Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program under their current eligibility category for a period of one year following the last day of the individuals pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.
(2)For purposes of this section, maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(c)(1)An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to this section shall submit to a county eligibility worker a note from that individuals treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individuals pregnancy.
(2)Notwithstanding paragraph (1), an individual who has had Medi-Cal coverage discontinued within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy and within the time limit described in subdivision (j) of Section 14005.37, may be reinstated to their previous Medi-Cal eligibility pursuant to subdivision (j) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individuals treating health care provider within the timeframe described in that subdivision.
(d)For purposes of this section, Medi-Cal program refers to any of the following programs:
(1)The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.
(2)The Medi-Cal program, as described in this article.
(3)The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).
(e)This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.
(f)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(g)Implementation of this section is subject to an appropriation in the annual Budget Act for these purposes.
(h)This section shall become inoperative commencing on the date that Section 14005.185 is implemented. If made inoperative, this section shall become operative again if, and upon the date that, Section 14005.185 is no longer implemented. The department shall determine the implementation status of Section 14005.185 and shall post, on the departments internet website, notice of its determination.
SEC. 2.Section 14005.251 is added to the Welfare and Institutions Code, immediately following Section 14005.25, to read:14005.251.(a)The department shall seek federal approval under Section 1115 of the federal Social Security Act to extend continuous eligibility to individuals over 19 years of age. Except as provided in Section 14005.39, an individual shall remain eligible pursuant to this subdivision from the date of a determination of eligibility for Medi-Cal benefits until either of the following circumstances applies:
(1)For existing Medi-Cal beneficiaries, the end of a 12-month period following the Medi-Cal eligibility determination at renewal.
(2)For new Medi-Cal applicants, the end of the 12-month period starting with the first month of Medi-Cal eligibility.
(b)This section shall be implemented only if, and to the extent that, federal financial participation is available.
(c)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar public and statewide instructions, until the time any necessary regulations are adopted. The department shall adopt regulations by January 1, 2027, 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.
SEC. 3.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)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, except as provided in Sections 14005.18, 14005.185, 14005.25, 14005.251, 14005.255, and 14005.39. 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 the county to attempt communication with the intended recipient through all additionally available channels prior to completing 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 completes processing of a beneficiarys redetermination following the procedures in this section, 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 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 the beneficiary 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 their 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 on 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 on which it is based.
(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 that 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.
(5)In the case of an annual redetermination, the county shall complete an eligibility determination at renewal without requesting additional information or documentation if either of the following sets of conditions is met:
(A)The following set of conditions:
(i)The most recent income determination was based on a previously verified attestation of income at or below 100 percent of the federal poverty level, including ex parte, electronic, or administrative verification, during either of the following:
(I)At the initial application.
(II)At the most recent renewal within the last 12 months.
(ii)The county has checked financial data sources and no information is received, but all other eligibility criteria are verified.
(iii)No contradictory information is on file.
(B)The following set of conditions:
(i)The most recent income determination, at either initial application or most recent renewal renewal, was within the last 12 months.
(ii)The beneficiary receives benefits under Title II of the federal Social Security Act or other sources of stable income at the most recent determination.
(iii)No contradictory information is on file.
(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 the beneficiary 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)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary twice 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 again review all information described in paragraph (1) of subdivision (e) in an attempt to renew eligibility without needing a response from a beneficiary. Only after completing these two steps may the county terminate the beneficiarys eligibility for Medi-Cal benefits following the provision of timely notice. The county shall not terminate eligibility until after it has processed all submitted renewal information.
(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 incomplete, the county shall follow the procedures set forth in paragraph (4) 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 states the information needed to redetermine 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. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions to 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.
(2)For applicants or beneficiaries, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods, when income is found not reasonably compatible from electronically available sources, the county shall first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. If that information is unavailable, the county shall obtain any other needed verification in order to complete the financial eligibility determination.
(3)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 require the county to attempt communication with the intended recipient through all additionally available channels prior to completing a redetermination. 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.
(4)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 twice by telephone, in writing, or other commonly available electronic means, in counties where that 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)In the case of a redetermination, for purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, a county shall accept self-attested information. For purposes of the income verification process only, the Medi-Cal beneficiary may provide verification through a verbal or written explanation.
(i)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.
(j)If, within 90 days of a Medi-Cal beneficiarys eligibility termination date or a change in eligibility status due to the beneficiarys failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. Unless the beneficiary opts out, the beneficiary shall be entitled to a Medi-Cal eligibility determination for the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(k)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.
(l)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 on 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 on disability.
(m)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.
(n)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.
(o)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.
(p)(1)In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population makes contact with the county, the county shall begin a new 12-month eligibility period if all of the following conditions are met:
(A)The county determines that the beneficiary remains eligible for Medi-Cal benefits.
(B)Utilization of change-in-circumstances data will not lead to a negative action.
(C)The individual has not reported, and the county has not obtained from external data sources, any information indicating a change in circumstances that results in a determination of ineligibility or an increase in share of cost.
(2)For purposes of this subdivision, vulnerable or difficult-to-reach population includes, but is not limited to, any of the following:
(A)Medi-Cal beneficiaries who are unsheltered or without a fixed address.
(B)Aged, blind, or disabled individuals.
(C)Victims of a natural disaster.
(D)Medi-Cal beneficiaries who live in a remote area.
(E)Incarcerated Medi-Cal beneficiaries.
(F)Migrant workers.
(G)Individuals in foster care.
(H)Unaccompanied immigrant minors.
(I)Any other population that the county determines is appropriate for designation as a vulnerable or difficult-to-reach population.
(q)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.
(r)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.
(s)(1)The department shall set a goal, in the form of a target rate of at least 50 percent, for successful ex parte renewals for populations, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods.
(2)The department shall prepare a report, excluding any personally identifiable information, on the causes of missing the target described in paragraph (1), if applicable, and action steps to increase ex parte renewal rates in months involving a failure to meet the target. The department shall post the report on the departments internet website.
(t)Counties shall collect and submit to the department call-center data metrics, including, but not limited to, call volume, average wait times, disconnects, callbacks, high-volume message recipients, and staff readiness.
(u)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (i), 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 website identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(v)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.
(w)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.
(x)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (4) 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. After the first attempt, the second attempt shall be through a different modality when the beneficiarys file includes a phone number or email address.
(y)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.
(z)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.
(aa)The department shall seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described in this section, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
(ab)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. 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.
(a)(1)An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
(2)For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.
(b)(1)Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program under their current eligibility category for a period of one year following the last day of the individuals pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.
(2)For purposes of this section, maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and, and includes, but is not limited to, postpartum depression.
(c)(1)An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to this section shall submit to a county eligibility worker a note from that individuals treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individuals pregnancy.
(2)Notwithstanding paragraph (1), an individual who has had Medi-Cal coverage discontinued within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy and within the time limit described in subdivision (i) (j) of Section 14005.37, may be reinstated to their previous Medi-Cal eligibility pursuant to subdivision (i) (j) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individuals treating health care provider within the timeframe described in that subdivision.
(d)For purposes of this section, Medi-Cal program refers to any of the following programs:
(1)The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.
(2)The Medi-Cal program, as described in this article.
(3)The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).
(e)This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.
(f)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(g)Implementation of this section is subject to an appropriation in the annual Budget Act for these purposes.
(h)This section shall become inoperative commencing on the date that Section 14005.185 is implemented. If made inoperative, this section shall become operative again if, and upon the date that, Section 14005.185 is no longer implemented. The department shall determine the implementation status of Section 14005.185 and shall post, on the departments internet website, notice of its determination.
SECTION 1.SEC. 2.Section 14005.251 is added to the Welfare and Institutions Code, immediately following Section 14005.25, to read:14005.251.(a)The department shall seek federal approval under Section 1115 of the federal Social Security Act to extend continuous eligibility to individuals over 19 years of age. Except as provided in Section 14005.39, an individual shall remain eligible pursuant to this subdivision from the date of a determination of eligibility for Medi-Cal benefits until either of the following circumstances applies:
(1)For existing Medi-Cal beneficiaries, the end of a 12-month period following the Medi-Cal eligibility determination at annual renewal.
(2)For new Medi-Cal applicants, the end of the 12-month period starting with the first month of Medi-Cal eligibility.
(b)This section shall be implemented only if, and to the extent that, federal financial participation is available.
(c)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar public and statewide instructions, until the time any necessary regulations are adopted. The department shall adopt regulations by January 1, 2027, 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.
SEC. 2.SEC. 3.Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.(a)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, except as provided in Sections 14005.18, 14005.185, 14005.25, 14005.251, 14005.255, and 14005.39. 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 the county to attempt communication with the intended recipient through all additionally available channels prior to completing 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 completes processing of a beneficiarys redetermination following the procedures in this section, 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 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 the beneficiary 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 their 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 on 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 on which it is based.
(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 that 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.
(5)In the case of an annual redetermination, the county shall complete an eligibility determination at renewal without requesting additional information or documentation if either of the following sets of conditions is met:
(A)The following set of conditions:
(i)The most recent income determination was based on a previously verified attestation of income at or below 100 percent of the federal poverty level, including ex parte, electronic, or administrative verification, during either of the following:
(I)At the initial application.
(II)At the most recent renewal within the last 12 months prior to the start of the continuous eligibility requirement. months.
(ii)The county has checked financial data sources and no information is received, but all other eligibility criteria are verified.
(iii)No contradictory information is on file.
(B)The following set of conditions:
(i)The most recent income determination, at either initial application or most recent renewal, was no earlier than 12 months prior to the start of the continuous eligibility requirement. renewal within the last 12 months.
(ii)The beneficiary receives benefits under Title II of the federal Social Security Act or other sources of stable income at the most recent determination.
(iii)No contradictory information is on file.
(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 the beneficiary 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)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary twice 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 again review all information described in paragraph (1) of subdivision (e) in an attempt to renew eligibility without needing a response from a beneficiary. Only after completing these two steps may the county terminate the beneficiarys eligibility for Medi-Cal benefits following the provision of timely notice. The county shall not terminate eligibility until after it has processed all submitted renewal information.
(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 incomplete, the county shall follow the procedures set forth in paragraph (5) (4) 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 states the information needed to redetermine 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. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions to 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.
(2)For applicants or beneficiaries, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods, when income is found not reasonably compatible from electronically available sources, the county shall first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. If that information is unavailable, the county shall obtain any other needed verification in order to complete the financial eligibility determination.
(3)For purposes of the income verification process only, when renewals are received without a reasonable explanation or other income verification, a county shall accept self-attested information. For purposes of the income verification process only, the Medi-Cal beneficiary may provide verification through a verbal or written explanation. The county shall accept self-attestation of income in cases that meet all of the following conditions:(A)The renewal packet is required.(B)No income waivers are applicable.(C)Utilization of the self-attested income will not lead to a negative action, such as discontinuance or moving from no share-of-cost to share-of-cost coverage.(4)(3)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 require the county to attempt communication with the intended recipient through all additionally available channels prior to completing a redetermination. 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.
(5)(4)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 twice by telephone, in writing, or other commonly available electronic means, in counties where that 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)In the case of a redetermination, for purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, a county shall accept self-attested information. For purposes of the income verification process only, the Medi-Cal beneficiary may provide verification through a verbal or written explanation.
(h)(i)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)(j)If, within 90 days of a Medi-Cal beneficiarys eligibility termination date or a change in eligibility status due to the beneficiarys failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. Unless the beneficiary opts out, the beneficiary shall be entitled to a Medi-Cal eligibility determination for the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(j)(k)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)(l)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 on 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 on disability.
(l)(m)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)(n)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)(o)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)(p)(1)In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population makes contact with the county, the county shall begin a new 12-month eligibility period if all of the following conditions are met:
(A)The county determines that the beneficiary remains eligible for Medi-Cal benefits.
(B)Utilization of change-in-circumstances data will not lead to a negative action.
(C)The individual has not reported, and the county has not obtained from external data sources, any information indicating a change in circumstances that results in a determination of ineligibility or an increase in share of cost.
(2)For purposes of this subdivision, vulnerable or difficult-to-reach population includes, but is not limited to, any of the following:
(A)Medi-Cal beneficiaries who are unsheltered or without a fixed address.
(B)Aged, blind, or disabled individuals.
(C)Victims of a natural disaster.
(D)Medi-Cal beneficiaries who live in a remote area.
(E)Incarcerated Medi-Cal beneficiaries.
(F)Migrant workers.
(G)Individuals in foster care.
(H)Unaccompanied immigrant minors.
(I)Any other population that the county determines is appropriate for designation as a vulnerable or difficult-to-reach population.
(p)(q)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.
(q)(r)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.
(r)(s)(1)The department shall set a goal, in the form of a target rate of at least 50 percent, for successful ex parte renewals for populations whose populations, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods.
(2)The department shall prepare a report, excluding any personally identifiable information, on the causes of missing the target described in paragraph (1), if applicable, and action steps to increase ex parte renewal rates in months involving a failure to meet the target. The department shall post the report on the departments internet website.
(s)(1)(t)Counties shall collect and submit to the department call-center data metrics, including, but not limited to, call volume, average wait times, disconnects, callbacks, high-volume message recipients, and staff readiness.
(2)The department shall prepare a report, excluding any personally identifiable information, on county call-center data, as described in paragraph (1), identified challenges, and targets or standards for improvement. The department shall post the report on the departments internet website on a quarterly basis.(t)(u)The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), (i), 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 website identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(u)(v)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.
(v)(w)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.
(w)(x)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (5) (4) 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. After the first attempt, the second attempt shall be through a different modality when the beneficiarys file includes a phone number or email address.
(x)(y)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.
(y)(z)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.
(z)(aa)The department shall seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described in this section, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
(aa)(ab)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.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.
(a)The department shall seek federal approval under Section 1115 of the federal Social Security Act to extend continuous eligibility to individuals over 19 years of age. Except as provided in Section 14005.39, an individual shall remain eligible pursuant to this subdivision from the date of a determination of eligibility for Medi-Cal benefits until either of the following circumstances applies:
(1)For existing Medi-Cal beneficiaries, the end of a 12-month period following the Medi-Cal eligibility determination at annual renewal.
(2)For new Medi-Cal applicants, the end of the 12-month period starting with the first month of Medi-Cal eligibility.
(b)This section shall be implemented only if, and to the extent that, federal financial participation is available.
(c)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar instructions, until the time any necessary regulations are adopted. The department shall adopt regulations by January 1, 2027, 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.
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 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. benefits, except as provided in Sections 14005.18, 14005.185, 14005.25, 14005.251, 14005.255, and 14005.39. 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 the county to attempt communication with the intended recipient through all additionally available channels prior to completing a 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 completes processing of a beneficiarys redetermination following the procedures in this section, makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis 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 the beneficiary 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 their 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 on 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. on which it is based.
(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 that 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.
(5)In the case of an annual redetermination, the county shall complete an eligibility determination at renewal without requesting additional information or documentation if either of the following sets of conditions is met:
(A)The following set of conditions:
(i)The most recent income determination was based on a previously verified attestation of income at or below 100 percent of the federal poverty level, including ex parte, electronic, or administrative verification, during either of the following:
(I)At the initial application.
(II)At the most recent renewal within the last 12 months prior to the start of the continuous eligibility requirement.
(ii)The county has checked financial data sources and no information is received, but all other eligibility criteria are verified.
(iii)No contradictory information is on file.
(B)The following set of conditions:
(i)The most recent income determination, at either initial application or most recent renewal, was no earlier than 12 months prior to the start of the continuous eligibility requirement.
(ii)The beneficiary receives benefits under Title II of the federal Social Security Act or other sources of stable income at the most recent determination.
(iii)No contradictory information is on file.
(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 the beneficiary 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)(C)The telephone number to call in order to obtain more information.
(2)The county shall attempt to contact the beneficiary twice 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 again review all information described in paragraph (1) of subdivision (e) in an attempt to renew eligibility without needing a response from a beneficiary. Only after completing these two steps may the county terminate the beneficiarys eligibility for Medi-Cal benefits following the provision of timely notice. The county shall not terminate eligibility until after it has processed all submitted renewal information.
(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 incomplete, the county shall follow the procedures set forth in paragraph (3) (5) 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 states the information needed to redetermine 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. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions to 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.
(2)For applicants or beneficiaries, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods, when income is found not reasonably compatible from electronically available sources, the county shall first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiarys self-attestation and information received through electronic data sources on required eligibility factors. If that information is unavailable, the county shall obtain any other needed verification in order to complete the financial eligibility determination.
(3)For purposes of the income verification process only, when renewals are received without a reasonable explanation or other income verification, a county shall accept self-attested information. For purposes of the income verification process only, the Medi-Cal beneficiary may provide verification through a verbal or written explanation. The county shall accept self-attestation of income in cases that meet all of the following conditions:
(A)The renewal packet is required.
(B)No income waivers are applicable.
(C)Utilization of the self-attested income will not lead to a negative action, such as discontinuance or moving from no share-of-cost to share-of-cost coverage.
(2)(4)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. require the county to attempt communication with the intended recipient through all additionally available channels prior to completing a redetermination. 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.
(3)(5)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 twice by telephone, in writing, or other commonly available electronic means, in counties where such that 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 a Medi-Cal beneficiarys eligibility termination date or a change in eligibility status due to the beneficiarys failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. The beneficiary shall be entitled to request a Medi-Cal eligibility determination for any of Unless the beneficiary opts out, the beneficiary shall be entitled to a Medi-Cal eligibility determination for the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(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 on 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 on 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)In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population makes contact with the county, the county shall begin a new 12-month eligibility period if all of the following conditions are met:
(A)The county determines that the beneficiary remains eligible for Medi-Cal benefits.
(B)Utilization of change-in-circumstances data will not lead to a negative action.
(C)The individual has not reported, and the county has not obtained from external data sources, any information indicating a change in circumstances that results in a determination of ineligibility or an increase in share of cost.
(2)For purposes of this subdivision, vulnerable or difficult-to-reach population includes, but is not limited to, any of the following:
(A)Medi-Cal beneficiaries who are unsheltered or without a fixed address.
(B)Aged, blind, or disabled individuals.
(C)Victims of a natural disaster.
(D)Medi-Cal beneficiaries who live in a remote area.
(E)Incarcerated Medi-Cal beneficiaries.
(F)Migrant workers.
(G)Individuals in foster care.
(H)Unaccompanied immigrant minors.
(I)Any other population that the county determines is appropriate for designation as a vulnerable or difficult-to-reach population.
(o)(p)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.
(p)(q)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.
(r)(1)The department shall set a goal, in the form of a target rate of at least 50 percent, for successful ex parte renewals for populations whose eligibility is determined using MAGI-based or non-MAGI-based financial methods.
(2)The department shall prepare a report, excluding any personally identifiable information, on the causes of missing the target described in paragraph (1), if applicable, and action steps to increase ex parte renewal rates in months involving a failure to meet the target. The department shall post the report on the departments internet website.
(s)(1)Counties shall collect and submit to the department call-center data metrics, including, but not limited to, call volume, average wait times, disconnects, callbacks, high-volume message recipients, and staff readiness.
(2)The department shall prepare a report, excluding any personally identifiable information, on county call-center data, as described in paragraph (1), identified challenges, and targets or standards for improvement. The department shall post the report on the departments internet website on a quarterly basis.
(q)(t)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 website identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r)(u)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)(v)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)(w)When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) (5) 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. After the first attempt, the second attempt shall be through a different modality when the beneficiarys file includes a phone number or email address.
(u)(x)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)(y)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.
(z)The department shall seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described in this section, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
(w)(aa)This section shall be implemented only if and to the extent that 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.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.
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Date
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Status
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|---|---|
| May 16, 2024 | In committee: Held under submission. |
| May 16, 2024 | Joint Rule 62(a), file notice suspended. (Page 5215.) |
| May 15, 2024 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Apr 22, 2024 | Re-referred to Com. on APPR. |
| Apr 18, 2024 | Read second time and amended. |
| Apr 17, 2024 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 13. Noes 0.) (April 16). |
| Mar 14, 2024 | Re-referred to Com. on HEALTH. |
| Mar 13, 2024 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 11, 2024 | Referred to Com. on HEALTH. |
| Feb 17, 2024 | From printer. May be heard in committee March 18. |
| Feb 16, 2024 | Read first time. To print. |
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Date
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Description
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Location
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Votes
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|---|---|---|---|---|
| Apr 16, 2024 | Do pass as amended 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
|
|---|---|---|
| Access Reproductive Justice | ** Support | |
| American Cancer Society Cancer Action Network Inc. | ** Support | |
| American Diabetes Association | ** Support | |
| Asian Americans Advancing Justice Southern California | ** Support | |
| Asian Resources, Inc. | ** Support | |
| Bay Area Legal Aid | ** Support | |
| Black Women For Wellness Action Project | * Support | Apr 16, 2024 |
| California Association Of Food Banks | ** Support | |
| California Chapter of the American College of Emergency Physicians | * Support | Apr 16, 2024 |
| California Coalition for Youth and Children Now | * Support | Apr 16, 2024 |
| California Dental Association | * Support | Apr 16, 2024 |
| California Hospital Association | * Support | Apr 16, 2024 |
| California Immigrant Policy Center | ** Support | |
| California Pan - Ethnic Health Network | ** Support | |
| California School-Based Health Alliance | ** Support | |
| California State Association of Psychiatrists | * Support | Apr 16, 2024 |
| California Wic Association | ** Support | |
| Canhr | ** Support | |
| Children Now | ** Support | |
| Children'S Specialty Care Coalition | ** Support | |
| ChildrenS Institute | ** Support | |
| Community Clinic Association of Los Angeles County | ** Support | |
| Community Health Councils | ** Support | |
| County of Santa Clara | ** Support | |
| Courage California | ** Support | |
| Friends Committee On Legislation Of California | ** Support | |
| Health Access | * Support | Apr 16, 2024 |
| Indivisible Ca Statestrong | ** Support | |
| Justice in Aging | ** Support | |
| Latino Coalition for a Healthy California | * Support | Apr 16, 2024 |
| Leading Age California | * Support | Apr 16, 2024 |
| Legal Services of Northern California | ** Support | |
| Local Health Plans Of California | * Support | Apr 16, 2024 |
| Oasis Legal Services | ** Support | |
| Planned Parenthood Affiliates Of California | * Support | Apr 16, 2024 |
| Public Law Center | ** Support | |
| Santa Clara County Board of Supervisors | * Support | Apr 16, 2024 |
| Second Harvest Food Bank of Orange County | ** Support | |
| Service Employees International Union | * Support | Apr 16, 2024 |
| Steinberg Institute | ** Support | |
| The Children's Partnership | * Support | Apr 16, 2024 |
| The Leukemia & Lymphoma Society | ** Support | |
| The Western Center on Law and Poverty | * Support | Apr 16, 2024 |
Date of Hearing: May 15, 2024
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Buffy Wicks, Chair
ABPCA Bill Id:AB 2956
Author:(Boerner) – As Amended Ver:April 18, 2024
Policy Committee: | Health | Vote: | 13 - 0 |
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| ||
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Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill requires the Department of Health Care Services (DHCS) to seek federal approval to extend numerous processes in the Medi-Cal program to establish continuous eligibility for Medi-Cal coverage to individuals over 19 years of age, for 12 months at a time, subject to the availability of federal financial participation and an appropriation for this bill in the annual Budget Act.
Specifically, this bill:
- Requires DHCS to seek federal approval to extend continuous eligibility to individuals over 19 years of age.
- Establishes continuous eligibility to individuals over 19 years old, which means they remain eligible for Medi-cal coverage 12 months from the date of determination of eligibility.
- Requires a county, in the event of loss of contact with a recipient, to attempt communication through additional channels prior to completing redetermination or terminating eligibility. Includes other provisions requiring a county’s efforts to reach beneficiaries for the purpose of renewing eligibility.
- Requires a county to complete eligibility determination at renewal without requiring additional information or documentation, if either a) or b), below, applies:
- All of the following are true:
- An individual's most recent income documentation was based on previously verified attestation of income at or below 100% of the federal poverty level (FPL) during initial application or at their most recent renewal within the last 12 months.
- The county has checked financial data sources and no information was received, but all other eligibility criteria have been verified.
- There is no contradictory information on file.
- All of the following are true:
- All of the following are true:
- The most recent income determination, at either initial application or most recent renewal within the last 12 months.
- The beneficiary receives Social Security benefits or other sources of stable income at the most recent determination.
- There is no contradictory information on file.
- All of the following are true:
- Prohibits a county from terminating eligibility until it has processed all submitted renewal information.
- Requires a county, when income is found not reasonably compatible from electronically available sources, to first attempt to obtain a reasonable explanation verbally or in writing, in an attempt to resolve discrepancies in financial information. Requires a county, if that information is unavailable, to obtain any other information needed to complete the financial eligibility determination. Includes various other requirements of a county to resolve missing information when redetermining eligibility.
- Modifies the process by which a beneficiary is entitled to receive retroactive eligibility based on the provision of information needed to complete an individual’s determination of eligibility, within 90 days of a termination date or change in eligibility status. Changes this process from one based on a beneficiary request, to an opt-out process whereby retroactive eligibility is granted unless the beneficiary opts out.
- Requires a county, in the case of a Medi-Cal beneficiary who is a member of a "vulnerable or difficult to reach population,” to begin a new, 12-month eligibility period each time the beneficiary makes contact with the county, if specified conditions are met. Defines vulnerable or difficult to reach populations as including: those without shelter or a fixed address; individuals with a disability; victims of a natural disaster; Medi-Cal beneficiaries who live in a remote area; incarcerated Medi-Cal beneficiaries; migrant workers; individuals in foster care; and unaccompanied immigrant minors, among others.
- Requires DHCS to set a target rate of at least 50%, for successful ex parte renewals for populations. Requires DHCS to prepare a public report on causes of missing the target, if applicable, and action steps to increase ex parte renewal rates.
- Requires counties to collect and submit to DHCS specified data metrics related to their call center operations.
FISCAL EFFECT:
DHCS estimates that, if the federal government approves some or all of the provisions proposed in this bill, additional costs to the Medi-Cal program would be $1 billion to $7 billion in the first six months, and $2 billion to $13 billion in the second year and ongoing, including health care services and systems costs (General Fund, federal funds). Some of these costs would likely be incurred absent this bill, as DHCS indicates it is considering continuing, through December 2024, some of the processes that help maintain eligibility, as the federal government has indicated it would allow states to continue doing so. DHCS indicates it is also expecting federal guidance on extending some of these processes past December 2024.
According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years.
COMMENTS:
- Purpose. This bill is sponsored by Western Center on Law and Poverty, the Children’s Partnership, and Latino Coalition for a Healthy California. According to the author:
With the public health emergency (PHE) now lifted, Medi-Cal renewals re-started last June. Over a million individuals lost their Medi-Cal coverage in the first six months of the unwinding period. Without the protections of temporary unwinding flexibilities, the overwhelming majority (92%) of Medi-Cal disenrollments have been for procedural or ‘paperwork’ reasons, meaning they are disenrolled by no fault of their own, even when they are likely still eligible for Medi-Cal. Of these, children and youth account for roughly one-third of all disenrollments in California. Furthermore, the data shows that people who speak Spanish as their primary language, seniors 65 and over and those with disabilities are disproportionately impacted by this issue.
Procedural disenrollments in Medi-Cal result in eligible people cycling on and off the program. This gap in healthcare coverage can lead to postponing visits to the doctor or not refilling a prescription. Not only does the disenrollment and re-enrollment process present yet another administrative hurdle for low-income Californians but also stresses overburdened and understaffed county social services agencies.
The Department’s actions to adopt numerous federal flexibilities have removed unnecessary barriers and burdens in the enrollment and renewal process, allowing millions of Californians to keep access to lifesaving health care. However, the federal flexibilities are scheduled to sunset in December 2024. If we let these policies expire, it will be much more difficult to bring them back and result in more procedural terminations.
Children already enjoy continuous eligibility for a full 12 months, regardless of changes in family income, and this bill would extend this continuous eligibility for adults. This reduces and remedies procedural terminations, simplifies the income verification requirements, increases automatic Medi-Cal renewals, and improves program outreach and customer service. These changes would reduce barriers to access associated with Medi-Cal renewals and protect the most vulnerable communities in California from losing healthcare coverage.
- Background. Federal requirements to “pause” redeterminations of Medi-Cal eligibility through the COVID-19 public health emergency (PHE) caused Medi-Cal enrollment to swell to a peak of 16 million people. As states resume redeterminations, the federal government has encouraged states to implement a number of strategies to simplify and reduce procedural disenrollments, or disenrollments due to lack of paperwork verification rather than a proactive determination of ineligibility. This resumption of redetermination processes is colloquially known as the “PHE unwinding.” This bill extends a number of the strategies, or “federal flexibilities,” the state implemented on a temporary basis during the PHE with respect to redetermination of eligibility. This bill also implements additional requirements that aim to retain more individuals in the program and create user-friendly eligibility processes.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: April 16, 2024
ASSEMBLY COMMITTEE ON HEALTH
Mia Bonta, Chair
ABPCA Bill Id:AB 2956
Author:(Boerner) – As Amended Ver:March 13, 2024
SUBJECT: Medi-Cal eligibility: redetermination.
SUMMARY: Extends numerous temporary federally allowable processes (federal flexibilities) related to the redetermination of Medi-Cal eligibility and establishes 12-month continuous Medi-Cal eligibility for adults. Federal flexibilities were put into place as part of a resumption of eligibility redeterminations, following a pause in redeterminations during the COVID-19 Public Health Emergency (the resumption of redeterminations and related processes are referred to as the “PHE unwinding”). Specifically, this bill:
- Establishes continuous eligibility to individuals over 19 years old, which means they remain eligible for 12 months from the date of determination of eligibility. For existing beneficiaries, this means for a 12 month period starting at renewal, and for new beneficiaries, for a 12 month period starting with the first month of eligibility.
- Requires a county to attempt communication through additional available channels prior to completing redetermination or terminating eligibility.
- Requires a county to complete eligibility determination at renewal without requiring additional information or documentation, if either:
- All of the following are true:
- An individual's most recent income documentation was based on previously verified attestation of income at or below 100% of the federal poverty level (FPL) during initial application or at their most recent renewal within the last 12 months;
- The county has checked financial data sources and no info was received, but all other eligibility criteria has been verified; and,
- There is no contradictory information on file;
- All of the following are true:
or,
- All of the following are true:
- The most recent income determination, at either initial application or most recent renewal within the last 12 months;
- The beneficiary receives Social Security benefits or other sources of stable income at the most recent determination; and,
- There is no contradictory information on file.
- All of the following are true:
- Deletes from existing law a requirement that a beneficiary must sign a renewal form if delivered in person or via mail.
- Requires a county to attempt to contact a beneficiary twice if a beneficiary has not responded to a request for additional information or has provided an incomplete response.
- Requires, if a beneficiary has not responded, a county to again review all information in an attempt to renew eligibility without needing a response from a beneficiary.
- Prohibits a county from terminating eligibility until it has processed all submitted renewal information.
- Requires, when income is found not reasonably compatible from electronically available sources, a county to first attempt to obtain a reasonable explanation verbally or in writing, in an attempt to resolve discrepancies in financial information. Requires counties, if that information is unavailable, to obtain any other information needed to complete the financial eligibility determination.
- Requires a county, if a redetermination is conducted based on a loss of contact with a beneficiary, to attempt communication through all additionally available channels prior to completing a redetermination. Requires, if the beneficiary does not supply the necessary information within a 30-day period, a 10-day notice of termination of Medi-Cal eligibility to be sent.
- Requires a county to attempt to contact a beneficiary twice by telephone or other means to request necessary information.
- In the case of a redetermination, for purposes of income verification, when a renewal is received without a reasonable explanation or other income verification, requires a county to accept self-attested information. Allows beneficiaries to provide income verification through a verbal or written explanation.
- Modifies the process by which a beneficiary is entitled to receive retroactive eligibility based on the provision of information needed to complete an individual’s determination of eligibility, within 90 days of a termination date or change in eligibility status. Changes this process from one based on a beneficiary request, to an opt-out process whereby retroactive eligibility is granted unless the beneficiary opts out.
- Requires a county, in the case of a Medi-Cal beneficiary who is a member of a "vulnerable or difficult to reach population,” a county to begin a new, 12-month eligibility period each time the beneficiary makes contact with the county, if specified conditions are met. Defines vulnerable or difficult to reach populations as including but not limited to:
- Medi-Cal beneficiaries who are unsheltered or without a fixed address;
- Aged, blind, or disabled individuals;
- Victims of a natural disaster;
- Medi-Cal beneficiaries who live in a remote area;
- Incarcerated Medi-Cal beneficiaries;
- Migrant workers;
- Individuals in foster care;
- Unaccompanied immigrant minors; and,
- Any other population that the county determines is appropriate for designation as a vulnerable or difficult-to-reach population.
- Requires the Department of Health Care Services (DHCS) to set a goal, in the form of a target rate of at least 50%, for successful ex parte renewals for populations.
- Requires DHCS to prepare a public report on causes of missing the target described in 14) above, if applicable, and action steps to increase ex parte renewal rates.
- Requires counties to collect and submit to DHCS specified data metrics related to their call center operations.
- Requires, in a county’s attempt to contact a beneficiary, a second attempt to be made through a different modality when the beneficiary’s file includes a phone number or email address.
- Requires DHCS to seek any necessary federal approvals to make permanent all temporary eligibility rules not included in this bill that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 unwinding period.
- Makes various conforming changes and conditions implementation on federal approval and the availability of federal financial participation.
EXISTING LAW:
- Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) § 14000 et seq.]
- Makes Medi-Cal eligibility and enrollment functions a county function and responsibility, subject to the direction, authority, and regulations of DHCS. [WIC § 14001.11]
- Establishes a processes for the determination and redetermination of an individual’s eligibility for Medi-Cal, as specified in 4) through 14), below. [WIC § 14005, et seq.]
- Requires a county to perform redeterminations of eligibility for beneficiaries every 12 months and promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstance that may affect eligibility. [WIC § 14005.37]
- Requires a loss of contact, as evidenced by the return of mail marked in such a way as to indicate it could not be delivered or that there was no forwarding address, to prompt a redetermination of eligibility. [Ibid.]
- Requires eligibility to continue during the redetermination process and prohibits eligibility from being terminated until the county makes a specific determination based on facts clearly demonstrating the beneficiary is no longer eligible, and due process rights have been met. [Ibid.]
- Requires, for purposes of acquiring information necessary to conduct eligibility redeterminations, a county to gather information available to the county that is relevant to the beneficiary’s eligibility, prior to contacting the beneficiary. Specifies state and federal data sources for this information. [Ibid.]
- Requires, if a county is able to make an eligibility determination based on accessible data, the county to notify the beneficiary of the determination and the information on which it is based, and requires the county to notify the beneficiary that they must inform the county if any of the information is inaccurate, but that the beneficiary is not required to sign and return the notice if all information is accurate. [Ibid.]
- Requires a beneficiary to sign a renewal form if the beneficiary chooses to return the form in person or via mail. [Ibid.]
- Requires, in the case of a redetermination due to a change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility, a county to send the beneficiary a form that states the information needed to redetermine eligibility, and limits the additional data a county can request from the beneficiary. [Ibid.]
- Requires a county to terminate eligibility if the purpose for a redetermination is loss of contact with the beneficiary, and the renewal form is also returned as undeliverable. [Ibid.]
- Requires, during the 30-day period after the date of mailing a form to the beneficiary requesting additional information for redetermination of eligibility, the county to attempt to contact the beneficiary to request necessary information. Requires, if the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of eligibility to be sent. [Ibid.]
- Specifies procedures whereby an individual can request to receive retroactive eligibility for the three months preceding an eligibility determination. [Ibid.]
- Requires a beneficiary to report any change in circumstance that may affect their eligibility within 10 calendar days following the date the change occurred. [Ibid.]
- As of January 1, 2025, contingent on funding, systems changes, and federal approval, makes a child continuously eligible for Medi-Cal up to five years of age and prohibits a redetermination of Medi-Cal eligibility before a child reaches five years of age, except in specified circumstances. [WIC § 14005.255]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, over a million individuals lost their Medi-Cal coverage in the first six months of the PHE unwinding period. Without the protections of temporary unwinding flexibilities, the overwhelming majority (92%) of Medi-Cal disenrollments have been for procedural or ‘paperwork’ reasons, meaning they are disenrolled by no fault of their own, even when they are likely still eligible for Medi-Cal. Of these, children and youth account for roughly one-third of all disenrollments in California. Furthermore, the data shows that people who speak Spanish as their primary language, seniors 65 and over and those with disabilities are disproportionately impacted by this issue.
The author notes procedural disenrollments in Medi-Cal result in eligible people cycling on and off the program. This gap in healthcare coverage can lead to postponing visits to the doctor or not refilling a prescription. Not only does the disenrollment and re-enrollment process present yet another administrative hurdle for low-income Californians, the author argues, but it also stresses overburdened and understaffed county social services agencies.
The author states DHCS’s actions to adopt numerous federal flexibilities have removed unnecessary barriers and burdens in the enrollment and renewal process, allowing millions of Californians to keep access to lifesaving health care. However, the federal flexibilities are scheduled to sunset in December 2024. If we let these policies expire, the author warns, it will be much more difficult to bring them back and result in more procedural terminations.
The author notes children already enjoy continuous eligibility for a full 12 months, regardless of changes in family income, and this bill would extend this continuous eligibility for adults. The author concludes this bill reduces and remedies procedural terminations, simplifies the income verification requirements, increases automatic Medi-Cal renewals, and improves program outreach and customer service. The author notes these changes would reduce barriers to access associated with Medi-Cal renewals and protect the most vulnerable communities in California from losing healthcare coverage.
- BACKGROUND. Federal requirements to “pause” redeterminations of Medi-Cal eligibility through the COVID-19 PHE caused Medi-Cal enrollment to swell to a peak of 16 million people. As states resume redeterminations, the federal government has encouraged states to implement a number of strategies to simplify and reduce procedural disenrollments, or disenrollments due to lack of paperwork verification rather than a proactive determination of ineligibility. This resumption of redetermination processes is colloquially called the “PHE Unwinding.” This bill extends a number of the strategies, or “federal flexibilities,” the state implemented on a temporary basis during the PHE Unwinding with respect to redetermination of eligibility. It also implements additional requirements that aim to retain more individuals on the program and create user-friendly eligibility processes.
- Basic Medi-Cal Eligibility Redetermination Requirements and Processes. As with most components of Medicaid, the federal government has rules establishing minimum requirements for eligibility groups that must be covered and eligibility rules that must be followed, and states have a variety of options in how they design their programs, as long as they seek federal approval for program changes.
Individuals who have been found eligible and are enrolled in Medi-Cal must have their eligibility redetermined every 12 months in order to retain coverage for the next year. If, during the 12-month period, new information that affects eligibility becomes available to the county, either reported by the individual or accessed through other electronic data sources, a beneficiary or enrollee will automatically have their eligibility redetermined based on the new information. Beneficiaries must report to the county any change in their circumstances that may affect their Medi-Cal eligibility within ten calendar days of the change.
To renew beneficiaries’ Medicaid coverage, states must first attempt to confirm ongoing eligibility using data available to the agency without requiring information from the individual. This requirement, also known as ex parte renewals, can reduce the administrative burden for states and simplify the process for beneficiaries. An ex parte renewal is a redetermination of eligibility that states can make based on reliable information available to the agency without requiring information from the individual.
The federal Patient Protection and Affordable Care Act (ACA) required states to implement data-sharing strategies to simplify eligibility and redetermination processes for beneficiaries. Medicaid and Children's Health Insurance Program (CHIP) agencies now rely primarily on information available through data sources (e.g., the Social Security Administration, the Departments of Homeland Security and Labor) rather than paper documentation from families for purposes of verifying eligibility.
State law establishes specific process requirements and due process safeguards for redeterminations of eligibility. Generally, a beneficiary has 30 days to respond to a request for information, if additional information is needed to establish eligibility. If the beneficiary does not provide the necessary information to the county within the 30-day period, the county may send the beneficiary a ten-day Notice of Action of terminating their eligibility. If terminated, the beneficiary still has 90 days from termination to “cure” or provide the information requested. Beneficiaries also have the right to appeal an adverse determination.
- COVID-19 PHE Redetermination Pause and Enrollment Growth. In 2020, federal legislation, the Families First Coronavirus Response Act, amended by the Coronavirus Aid, Relief, and Economic Security Act, authorized a 6.2 percentage point increase in federal Medicaid matching funds to help states respond to the COVID-19 pandemic. As a condition of receiving enhanced funds, states were required to provide continuous eligibility through the end of the month in which the public health emergency ends for those enrolled as of March 18, 2020 or at any time thereafter during the PHE period, unless the person ceased to be a state resident or requested a voluntary coverage termination. The state paused redetermination activities and, as a result, from July 2020 through July 2023, Medi-Cal enrollment increased by approximately 2.6 million people.
Subsequent federal legislation, the Consolidated Appropriations Act (CAA) of 2023, delinked the continuous coverage requirements from the PHE. Pursuant to the CAA, continuous coverage requirements ended on March 31, 2023 and the PHE Unwinding began as of April 1, 2023.
As a result, Medi-Cal redeterminations resumed in June 2023. The first Medi-Cal eligibility terminations occurred on July 1, 2023. Between June 2023 and May 2024, Medi-Cal members will have their eligibility redetermined based on their “renewal month,” in order to maintain beneficiaries on coverage and spread redetermination workload throughout the year.
- PHE Unwinding and Federal Flexibilities. Preparing for and implementing the PHE Unwinding has been a major effort for DHCS and counties. Many enrollment workers hired during the pandemic had never processed a redetermination, and counties have been struggling with staff shortages and burnout. A large number of beneficiaries changed addresses and contact information, and many had never had their Medi-Cal eligibility redetermined and are not familiar with required paperwork and processes. Despite the heavy lift for all involved, DHCS has indicated it prioritized maximizing continuity of coverage for Medi-Cal beneficiaries throughout the PHE Unwinding.
According to the federal Centers for Medicare and Medicaid Services (CMS) that oversees state Medicaid programs, many individuals enrolled in Medicaid and other programs lose coverage at renewal due to procedural or administrative reasons rather than eligibility-related factors, such as not submitting information needed to complete their renewal in a timely fashion. To prevent inappropriate coverage loss among eligible individuals, CMS advises states to implement actionable strategies to strengthen their renewal processes and avoid such procedural disenrollments.
Through guidance to states, including through State Health Official letter 22-001 and subsequent guidance such as a December 18, 2023, Center for Medicaid & CHIP Services Informational Bulletin, CMS laid out a number of targeted enrollment strategies that can be used to facilitate renewals, leading to fewer discontinuances during the 12-month unwinding period. Specifically, CMS has identified and made available to states temporary waivers allowable under the Social Security Act. According to KFF, a nonprofit health news source that tracks state Medicaid trends, nearly all states adopted one or more of these temporary waivers.
- PHE Unwinding and Federal Flexibilities. Preparing for and implementing the PHE Unwinding has been a major effort for DHCS and counties. Many enrollment workers hired during the pandemic had never processed a redetermination, and counties have been struggling with staff shortages and burnout. A large number of beneficiaries changed addresses and contact information, and many had never had their Medi-Cal eligibility redetermined and are not familiar with required paperwork and processes. Despite the heavy lift for all involved, DHCS has indicated it prioritized maximizing continuity of coverage for Medi-Cal beneficiaries throughout the PHE Unwinding.
According to “California’s Journey with Medi-Cal Redeterminations,” an issue brief published by the California Health and Human Services Agency (CHHSA issue brief), California implemented 17 flexibilities approved by CMS through waiver authority or under existing federal Medicaid law to streamline enrollment and keep individuals in coverage as the Medi-Cal redetermination process restarted. These flexibilities are extended by this bill, and include many income-based and administrative waivers and flexibilities that make the redetermination process easier for beneficiaries.
- Recent State Experience; Improvements in Ex Parte Renewals. According to DHCS, recent nationwide data on Medicaid unwinding of the COVID-19 emergency continuous coverage provision show that a majority of disenrollments occurred due to procedural reasons (e.g., late submission of paperwork, failure to respond to a state’s request for information, lost forms), rather than legitimate losses of eligibility (i.e., changes in income or circumstances that would make individuals ineligible for Medicaid).
California recently partnered with the United States Digital Services (USDS) to automate income-based waivers in the state’s Medi-Cal eligibility and enrollment systems. According to the CHHSA issue brief, starting in August 2023, USDS provided engineering and system design support to the state policy team and state’s system vendor teams to expedite implementation timelines. USDS identified opportunities to improve the steps in the ex parte renewal process that would have the greatest impact on the ex parte renewal rate. With the USDS’s assistance, the state’s ex parte rate significantly increased from an average of 34% from June to November to 66% in December 2023. With the increase in ex parte, California’s overall Medi-Cal disenrollments dropped from around 20% to nine percent in December.
- Churn and Continuous Eligibility. States conduct annual renewals of Medicaid eligibility, but enrollees are required to report changes in circumstances, such as changes in family income, during the year. This can lead to “churn,” where individuals go through short periods of disenrollment and re-enrollment in coverage, leading to disruptions in coverage and lapses in continuity of care. According to DHCS, people who experience churn are more likely to delay or forego care, receive less preventive care, stop filling their prescriptions, and have more emergency department visits. Furthermore, DHCS notes, churn has health equity implications. DHCS notes one study found Black and Hispanic Medicaid members were more likely to be disenrolled and reenrolled within 12 months compared to their white counterparts.
Continuous eligibility guarantees 12 months of continuous coverage even if there are fluctuations in income. The CAA required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. California has had this in place for children up to age 19 since 2000. SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, implemented continuous eligibility for children younger than age five, but made the bill contingent on appropriation and the availability of funds. Although the Governor’s January 2024 Budget did not fund this item based on the poor General Fund condition, as of January 2024, DHCS is seeking federal approval to make this change when funding allows.
KFF notes five states have some level of continuous eligibility for adults and other states are pursuing this option to help to provide more stable coverage once the unwinding period ends. California has not pursued 12-month continuous eligibility for adults, which this bill would implement.
- Effect of This Bill. This bill extends a number of temporary federal waivers as noted below.
- Income under 100% FPL, zero income, or “stable income.” The temporary flexibilities, effective June 1, 2023, through the end of the unwinding period, allow for automatic determination of income for households whose attestation of income under 100 % FPL was verified within the last 12 months (at application or renewal) when no income information is returned through data sources, which will allow more beneficiaries with low income to have the annual renewal completed through ex-parte and without the need to complete an annual renewal packet. This bill will extend such flexibility indefinitely. This bill also extends automatic determination of income to individuals who receive payments under the Social Security disability insurance program or “other stable sources of income” and have no other conflicting income information on file. Furthermore, this bill extends to individuals who were verified at 100% FPL or below at the time of their initial application, i.e., without requiring 100% or lower income to be verified within the last 12 months. According to the CHHSA brief, these changes have had the largest impact on improving the ex parte renewal rate.
- Additional contact attempts to households with incomplete renewals or loss of contact. DHCS implemented an additional contact requirement to help mitigate possible procedural terminations during the PHE Unwinding period. DHCS issued Medi-Cal Eligibility Division Information Letter (MEDIL-24-09) to advise counties this change is being made permanent, and this bill codifies this change. This bill also requires a second contact attempt to be made through a different modality, such as phone or email, if such information is available. It also requires counties to make additional attempts to contact beneficiaries if return mail indicates a loss of contact.
- Renew at any time for hard-to-reach populations. The temporary flexibility allows counties to renew people at any time, instead of having to wait for assigned renewal month. This helps maintain hard-to-reach populations on the program. This bill will require a county to begin a new 12-month eligibility period for hard-to-reach populations if specified conditions are met.
- Allow counties to continue attempting to renew, after a renewal packet is sent. The temporary flexibility allows counties, after a renewal packet is sent, to still use other information to process the renewal, without requiring return of the packet or additional information. This bill would make the change permanent.
- “Reasonable compatibility threshold” for income. Counties use a standard to determine whether or not the income in federal data sources is compatible with the information an individual reports. The temporary flexibility allows counties to verify income on an ex parte basis when attested income is below the FPL, and income reported through electronic sources is no greater than 20% higher than the FPL limit. In the state’s Modified Adjusted Gross Income (MAGI)-Based Eligibility Verification Plan, DHCS indicates it plans to reduce this threshold reduced to 10% in June 2024, assuming the 12-month resumption to normal operations has concluded at that time. This bill would maintain the 20% threshold permanently and implement it for all populations, including those who have income counted using the MAGI method as well as “non-MAGI” populations.
- Reasonable explanations. CMS allows states to permit an applicant or beneficiary to provide a reasonable explanation why their self-attested information did not align with electronic verification sources in order to complete the Medi-Cal eligibility determination. In the state’s MAGI-Based Eligibility Verification Plan, DHCS notes effective July 1, 2022, California implemented the use of reasonable explanation as part of the verification process, which is conducted on a manual basis until July 2024, when systems will be automated to obtain a reasonable explanation at application, annual renewal or a change in circumstance. If certain reasonable explanations are selected, income will be verified automatically and eligibility will be determined "real time" without additional verification. This bill codifies these processes.
- Self-attestation of income. Per MEDIL I 23-49E, renewals received without a reasonable explanation or new income verification can use self-attested information under a federally approved waiver. Effective October 1, 2023, DHCS notes, the waiver will allow the acceptance of self-attestation of income for instances where the renewal packet is required, no income waivers are applicable, and utilization of the self-attested income will not lead to a negative action such as discontinuance. Counties must still follow normal business processes to verify all other required non-financial eligibility criteria. This bill continues the provisions of the Self-Attestation of Income Waiver.
- Improvements to 90-day cure period. The temporary flexibility makes submissions of information during 90-day cure period automatically restore Medi-Cal eligibility back to date of discontinuance, when person is found eligible based on the new information. This bill would extend the flexibility.
- All other flexibilities. The following federal unwinding waivers and flexibilities are included in a comprehensive list in the CHHSA issue brief. These additional flexibilities do not appear to be specifically addressed by this bill, but would be maintained by the bill’s catch-all extension of all temporary flexibilities not specifically added by the bill. They include:
- Partnering with the National Change of Address Database and United States Postal Service In-State Forwarding Address to update member contact information;
- Partnering with Program of All-Incisive Care for the Elderly organizations to update member contact information;
- Extending the timeframe for members to request a State Fair Hearing from 90 to 120 days;
- Extending timeframe to take final administrative action on State Fair Hearing requests from 90 to 120 days;
- Suspending the requirement to apply for other benefits;
- Suspending the requirement to cooperate with child support agencies in establishing the identity of a child’s parents and in obtaining medical support; and,
- Using Medi-Cal managed care plans and all available outreach modalities (phone call, email, text) to contact members when renewal forms are mailed and when they should have received them by mail. (This bill requires outreach by multiple modalities but does not specifically reference the role of managed care plans.)
- Effect of This Bill. This bill extends a number of temporary federal waivers as noted below.
This bill also imposes requirements that are not directly related to and go beyond the PHE-era flexibilities, but are also meant to improve customer service for eligibility functions and make it easier to stay on Medi-Cal. These include:
- Continuous eligibility. This bill would implement 12-month continuous eligibility for adults regardless of changes in circumstances. Although this wasn’t specifically one of the federal flexibilities under the PHE, the pause of redeterminations essentially created continuous eligibility for adults during that time period.
- Require a manual review before eligibility is terminated. This bill would prohibit eligibility from being automatically terminated without a manual review. It would require counties to review information on each case before discontinuing eligibility. According to the sponsor, this provision would help ensure individuals are not terminated from the program when they may be eligible under other eligibility pathways, and would ensure all information has been processed prior to eligiblity being terminated.
- Requiring reporting of call center metrics. Counties are not currently required to report on call center metrics, such as wait times. This bill would require such reporting.
- Set ex parte success rate goals and require mitigations if goals not met. According to the sponsor, the Center for Budget and Policy Priorities recommends states set goals for the percentage of renewals that are conducted on an ex parte basis. This bill requires DHCS to set a target of at least 50% successful ex parte for the MAGI population, and to submit a report on causes of missing target and action steps to increase ex parte rates in months they fail to meet the target.
- Streamlining. This bill removes a requirement for a beneficiary to sign a renewal form if returned to the county in person or by mail. Individuals can currently respond to the county with information through other means, including email or telephone.
- SUPPORT. Numerous consumer, legal aid, and children’s advocates support this bill because it will maintain low-income children, adults and families on Medi-Cal, reduce procedural barriers, and improve customer service for individuals seeking help.
- RELATED LEGISLATION. SB 1287 (Roth) requires counties to report call center metrics. SB 1287 is pending in the Senate Health Committee.
- PREVIOUS LEGISLATION. SB 184 implemented continuous eligibility for children younger than age five, contingent on funding, federal approval, and systems readiness.
- POLICY COMMENT. The changes imposed by the pause in redetermination and the PHE Unwinding provided an opportunity for the state, county, and system stakeholders to step back and reassess the performance of the Medi-Cal eligibility system, and think critically about the costs and benefits of eligibility requirements. Since the ACA, the state and federal government have moved firmly toward a smarter, more user-friendly system that minimizes burden on individuals to provide information necessary retain coverage, which has many benefits, including easing administrative workload and stabilizing coverage for individuals and families. Further careful analysis and technical assistance from DHCS and engagement with counties is advised to ensure the language in the bill extends flexibilities as intended and, where this bill goes beyond what was approved under temporary flexibilities to create permanent, ongoing business processes, that appropriate safeguards are in place against unintended consequences, such as a situation in which automatic ex parte renewals “auto-verify” each other indefinitely.
In addition, as this bill moves forward, in consultation with DHCS and to provide all parties clarity over the long term, the author may wish to eliminate the provision extending all other temporary flexibilities not specifically enumerated, and instead specifically enumerate all these rules in statute. - TECHNICAL AMENDMENTS. The Committee, author, and sponsor have identified the following minor technical amendments:
- Section 14005.251. (a) The department shall seek federal approval
under Section 1115 of the federal Social Security Actto extend continuous eligibility to individuals over 19 years of age. - Section 14005.37 (e)(5)(B)(i) The most recent income determination, at either initial application or most recent renewal, was within the last 12 months.
- Section 14005.251. (a) The department shall seek federal approval
REGISTERED SUPPORT / OPPOSITION:
Support
Access Reproductive Justice
American Cancer Society Cancer Action Network INC.
American Diabetes Association
Asian Americans Advancing Justice-southern California
Asian Resources, INC.
Bay Area Legal Aid
California Association of Food Banks
California Dental Association
California Immigrant Policy Center
California Pan - Ethnic Health Network
California School-based Health Alliance
California State Association of Psychiatrists (CSAP)
California State Council of Service Employees International Union (SEIU California)
California WIC Association
CANHR
Children Now
Children's Institute
Children's Specialty Care Coalition
Community Clinic Association of Los Angeles County (CCALAC)
Community Health Councils
County of Santa Clara
Courage California
Friends Committee on Legislation of California
Health Access California
Indivisible CA StateStrong
Justice in Aging
Latino Coalition for A Healthy California
LeadingAge California
Legal Services of Northern California
Oasis Legal Services
Public Law Center
Second Harvest Food Bank of Orange County
Steinberg Institute
The Children's Partnership
The Leukemia & Lymphoma Society
Western Center on Law & Poverty
Opposition
None on file.
Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097
Bill Author
Bill Co-Author(s):
