Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

The bill would require a county with a call center as described above, commencing on January 1, 2026, and each month thereafter, to collect and submit to the department call-center data metrics, including, among other information, total call volume, average call wait times by language, and average call abandonment rate. By creating new duties for counties relating to call-center data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on call-center data. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter, with the initial report due on May 15, 2026.

The bill would require the department to implement these provisions, without taking any regulatory action, by means of an all-county letter or similar instruction. The bill would require the department to adopt regulations thereafter in accordance with certain provisions.

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 and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

The bill would require a county with a call center as described above, commencing on January 1, 2026, and each month thereafter, to collect and submit to the department call-center data metrics, including, among other information, total call volume, average call wait times by language, and average call abandonment rate. By creating new duties for counties relating to call-center data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on call-center data. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter, with the initial report due on May 15, 2026.

The bill would require the department to implement these provisions, without taking any regulatory action, by means of an all-county letter or similar instruction. The bill would require the department to adopt regulations thereafter in accordance with certain provisions.

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 and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

The bill would require a county with a call center as described above, commencing on April 1, 2025, January 1, 2026, and each quarter month thereafter, to collect and submit to the department call-center data metrics, including, among other information, total call volume, average call wait times by language, and callbacks. average call abandonment rate. By creating new duties for counties relating to call-center data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on call-center data. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter, with the initial report due on May 15, 2025. 2026.

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 and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

This bill would require the department to establish, with stakeholder input, statewide minimum standards for assistance provided by a countys call center to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. The bill would require promulgation of the standards in regulation by July 1, 2026, as specified.

The bill would require a county with a call center as described above, commencing on April 1, 2025, and each quarter thereafter, to collect and submit to the department call-center data metrics, including, among other information, call volume, average call wait times by language, and callbacks. By creating new duties for counties relating to call-center data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on call-center data, identifying challenges and targets or standards for improvement. data. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter, with the initial report due on May 15, 2025.

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 and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

This bill would require the department to establish establish, with stakeholder input, statewide minimum standards for assistance provided by county call centers a countys call center to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. The bill would require promulgation of the standards in regulation by July 1, 2026, as specified. The bill would authorize the department to develop alternate standards for a county that does not operate a call center for Medi-Cal applicants and beneficiaries.

The bill would require a county with a call center as described above, commencing on April 1, 2025, and each quarter thereafter, to collect and submit to the department on April 1, 2025 and each quarter thereafter call-center data metrics, including, among other information, call volume, average call wait times by language, and callbacks. Commencing on July 1, 2025, and each quarter thereafter, the bill would require a county that does not operate a call center for Medi-Cal applicants and beneficiaries to collect and submit to the department approved alternative metrics. By creating new duties for counties relating to call call-center data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on county call call-center data, identifying challenges and targets or standards for improvement. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter. The bill would require the initial report on county call-center data from counties operating call centers to be quarter, with the initial report due on May 15, 2025.

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 and 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 sets forth various responsibilities for counties relating to eligibility determinations and enrollment functions under the Medi-Cal program.

Existing federal law sets forth Medicaid reporting requirements for each state during the period between April 1, 2023, and June 30, 2024, inclusive, relating to eligibility redeterminations, including, among other information, the total call-center volume, average wait times, and average abandonment rate for each call center of the state agency responsible for administering the state plan, as specified.

This bill would require the department to establish statewide minimum standards for assistance provided by county call centers to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. The bill would require promulgation of the standards in regulation by July 1, 2026, as specified. The bill would authorize the department to develop alternate standards for a county that does not operate a call center for Medi-Cal applicants and beneficiaries.

The bill would require a county to collect and submit to the department on April 1, 2025 and each quarter thereafter call-center data metrics, including, among other information, call volume, average call wait times by language, and callbacks. Commencing on July 1, 2025, and each quarter thereafter, the bill would require a county that does not operate a call center for Medi-Cal applicants and beneficiaries to collect and submit to the department approved alternative metrics. By creating new duties for counties relating to call-center call data, the bill would impose a state-mandated local program.

The bill would require the department to prepare a report, excluding any personally identifiable information, on county call-center call data, identifying challenges and targets or standards for improvement. The bill would require the department to post the report on its internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter, with the initial report due on May 15, 2025. quarter. The bill would require the initial report on county call-center data from counties operating call centers to be due on May 15, 2025.

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 and 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 sets forth a schedule of benefits under the Medi-Cal program.

This bill would make technical, nonsubstantive changes to provisions relating to that schedule of benefits.

 UNFINISHED BUSINESS  

Bill No: SB 1289

Author: Roth (D)

Amended: 8/19/24

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 4/24/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/16/24

AYES: Caballero, Jones, Ashby, Becker, Bradford, Seyarto, Wahab

SENATE FLOOR: 39-0, 5/21/24

AYES: Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

NO VOTE RECORDED: Allen

ASSEMBLY FLOOR: 76-0, 8/27/24 - See last page for vote

SUBJECT: Medi-Cal: call centers: standards and data

SOURCE: Coalition of California Welfare Rights Organizations

Western Center on Law & Poverty

DIGEST:

This bill requires counties operating call centers to collect and submit call-center metrics and DHCS to report on those metrics on a quarterly basis on its website.

Assembly Amendments

delete provisions requiring the Department of Health Care Services (DHCS) to establish statewide minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients.

ANALYSIS:

Existing federal law requires states to use a single, streamlined application that may be filed online, in person, by mail, or by telephone to apply for enrollment through the state’s Medicaid, CHIP, or health subsidy program. [42 USC §18083]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Delegates to the county of residence the responsibility for Medi-Cal eligibility determinations and ongoing case management. [WIC §14015.5]
3. Gives individuals the option to apply for Medi-Cal in person, by mail, online, by telephone, or by other commonly available electronic means. Requires renewal procedures to include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means. [WIC §15926]
4. Requires a county to perform redeterminations of eligibility for Medi-Cal recipients every 12 months and to promptly redetermine eligibility whenever the county receives information about changes in a recipient’s circumstances that may affect eligibility for Medi-Cal benefits. Allows a recipient to provide information regarding a change in circumstances or requested by the county over the telephone. Allows recipients to provide signatures over the telephone for forms that are required to be signed. [WIC §14005.37]
5. Requires a county to notify a Medi-Cal recipient when their Medi-Cal eligibility worker changes and to include in the notice the worker’s telephone number and hours during which the eligibility workers may be contacted. [WIC §14005.33]
6. Requires DHCS to provide assistance over the telephone to any applicant or recipient that requests help with the application or redetermination process. [WIC §14000.7]

This bill:

1. Requires a county with a call center for Medi-Cal applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage to collect and submit to the DHCS call-center data metrics, including, but not limited to, total call volume, average call wait times by language, and the average call abandonment rate, starting January 1, 2026 and each month thereafter.
2. Requires DHCS to prepare a report, excluding any personally identifiable information, on call-center data described in 1) above. Requires DHCS to post the report on its website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter starting May 15, 2026.
3. Permits reimbursement to local agencies for costs if the Commission on State Mandates determine that this act contains costs mandated by the state.

Comments

1. Author’s statement. According to the author, “for years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and call disconnects. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements allowing people to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. When Medi-Cal recipients who lost their coverage during this recent renewal effort were surveyed, one third who tried to complete their renewal responded that they called their county but got no answer, were on hold too long, or got disconnected. This bill would require DHCS to develop minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients, and to collect and report county call center data.”
2. Medi-Cal eligibility and “no wrong door.” The Affordable Care Act required states to create a single-streamlined application for all insurance affordability programs (Medicaid and the Children’s Health Insurance Program, which are joined as Medi-Cal in California, and the state health exchange, Covered California) that could be submitted in person, online, via mail, or by telephone. In California, applications for the Medi-Cal program are processed by county eligibility workers, thus in order to apply by phone, an applicant needs to call the county. Federal and state law also specify that applicants may call the county to provide additional information if they get a notice that information is missing from their application. Allowing for telephone access is part of a “no wrong door” philosophy that ensures that the Medi-Cal program is accessible to all who are eligible, including those with low vision, low literacy, lack of access to computers, or any other barriers that might make filling out a paper or online application difficult.
3. Medi-Cal renewals and the public health emergency unwinding. Medi-Cal recipients are required to report to the county any changes in circumstances that might affect their eligibility, such as a change in income or household size. They are also required to have their eligibility redetermined every 12 months if no other changes in circumstances have occurred. Just as applicants have the right to apply for the program by phone, Medi-Cal recipients can also provide information needed to complete redetermination over the phone. Counties are required to first do an ex parte review of an individual’s Medi-Cal case to determine if the county already has enough information based on state and federal databases to renew an individual, and if not, ask the individual only for the information that is needed to complete an eligibility determination. If there is missing information, the individual would need to provide that to the county, either by phone, or by sending the information in. Sometimes an individual need only provide an explanation, such as in cases where income one month is not expected to reflect what that individual’s annual income would be because the individual no longer has the job or had their hours cut.

California is currently redetermining all Medi-Cal recipients following years of continuous eligibility for everyone during the COVID-19 public health emergency, regardless of changes in circumstances. As a result, many people have lost Medi-Cal due to procedural terminations (i.e., a county was unable to determine whether the individual was actually eligible due to missing information). Given the long wait times that recipients are experiencing when trying to contact their county by phone, DHCS recently released guidance to county welfare directors encouraging the use of interactive voice response (IVR) as part of their call-in process to include messaging about renewal assistance available within the county. DHCS’s guidance suggests that the IVR messaging direct callers to an outside community-based organization, health plan, or navigator. It should be noted that while these other entities can answer basic questions about the Medi-Cal program, they cannot redetermine eligibility.

DHCS has partnered with the California Health Care Foundation to survey individuals who have been procedurally disenrolled from Medi-Cal during this continuous coverage unwinding period in order to identify barriers that are causing these disenrollments. The latest survey of individuals who were procedurally disenrolled on January 1, 2024 found that of those that received a renewal form and completed or tried to complete it, 35% said that they called the county but got no answer, were on hold too long, or got disconnected. The survey also found that Hispanic respondents were significantly more likely to experience challenges as compared to White respondents.

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

According to the Assembly Appropriations Committee, this bill would have total costs potentially in the low to mid-millions of dollars (50% General Fund (GF), 50% federal funds (FF)) in fiscal year (FY) 2025-26 and low millions (50% (GF), 50% (FF)) in FY 2026-27 and ongoing, as follows (costs are 50% GF, 50% FF):

1. Costs of approximately $1.3 million (50% (GF), 50% (FF)) in FY 2025-26 and annually thereafter for eight staff at DHCS to perform call center monitoring activities, work with counties, and provide data support.
2. Annual, ongoing county costs potentially in the low to mid-millions of dollars, including staffing for up to 53 full-time equivalent positions statewide to perform additional duties, such as collecting statistical data from systems-linked call centers (50% (GF), 50% (FF)).
3. Unquantified costs for equipment, software licenses and maintenance agreements.

SUPPORT: (Verified 8/26/24)

Coalition of California Welfare Rights Organizations (co-source)

Western Center on Law & Poverty (co-source)

Asian Americans Advancing Justice Southern California

Asian Resources, Inc.

Bet Tzedek Legal Services

California Association of Food Banks

California Advocates for Nursing Reform

California Council of Community Behavioral Health Agencies

California Primary Care Association Advocates
Children Now

Community Clinic Association of Los Angeles County

Community Legal Aid SoCal

Grace Institute

Justice in Aging

Latino Coalition for a Health California

Legal Services of Northern California

Maternal and Child Health Access

National Health Law Program

Northeast Valley Health Corporation

Para Los Ninos

Parent Engagement Academy

Second Harvest Food Bank of Orange County

South Asian Network

The Children’s Partnership

Venice Family Clinic

OPPOSITION: (Verified 8/26/24)

County Welfare Directors Association of California (unless amended)

ARGUMENTS IN SUPPORT: Co-sponsors Western Center on Law & Poverty and Coalition of California Welfare Rights Organizations write that people are struggling to reach county workers by phone and wait times can exceed five hours. Even in counties with shorter wait times, actual processing times are much longer. For instance, Los Angeles County averages a 30-minute wait time with a ticket system that workers process later. At any time, approximately 40,000 of those tickets are languishing in queue, waiting to be processed. Meanwhile, Californians are losing their health coverage. Legal Services of Northern California gives an example of one person in Santa Cruz who spent four months trying to disenroll from Medi-Cal when her income went up so that she could enroll in Covered California. In another example, a couple submitted their renewal packet but were still disenrolled. While trying to contact an eligibility worker, one of them had to delay an eye surgery and the other incurred over $1,000 in medical debt after an emergency room visit.

Supporter the Community Clinic Association of Los Angeles County writes that over the past 10 year, enrollment counselors and health navigators that work in their member clinics have struggled with wait times, disconnects and other challenges reaching county eligibility workers quickly by phone. Enrollment staff typically spend anywhere from 45 minutes to 3 hours waiting to connect and working to resolve issues. Generally, patients need to be on the line as well, adding further to the burden. Like most health care entities, health centers struggle with staff bandwidth, and cannot have employees spend hours of their workday waiting on hold. If patients simply cannot spend the needed time waiting, coverage can lapse, and patients cannot get the services, referrals, or medications they were seeking.

ARGUMENTS IN OPPOSITION: The California Welfare Directors Association opposes this bill unless amended, expressing concerns about the technical ability of counties to collect data specified by the bill and concerns about the comparability of metrics as applied to different call center models. They previously expressed concerns about a prior version of the bill that would have required DHCS to impose customer service standards on the counties, but these concerns are no longer relevant.

ASSEMBLY FLOOR: 76-0, 8/27/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Megan Dahle, Davies, Essayli, Flora, Mike Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Cervantes, Dixon, Ortega

Prepared by: Jen Flory / HEALTH / (916) 651-4111

8/27/24 18:48:33

**** END ****

SENATE THIRD READING

STR Bill Id:SB 1289

Author:(Roth)

As Amended Ver:August 19, 2024

Majority vote

SUMMARY

Requires Department of Health Care Services (DHCS) to collect data and publish a quarterly report with specified metrics, such as average wait time, for county-administered customer service call centers that process Medi-Cal eligibility and enrollment.

Major Provisions

COMMENTS

1. Basic Medi-Cal Eligibility Redetermination Requirements and Processes. Medicaid is a state-federal program, and states have a variety of options in program design as long as they meet federal requirements. In California's Medi-Cal program, counties are responsible for eligibility and enrollment functions. This includes things like determining individuals’ initial eligibility to enroll in the program, maintaining accurate records on individuals’ ongoing eligibility, and administering regular eligibility redeterminations. Counties also are responsible for similar functions in major human services programs, including California Work Opportunity and Responsibility to Kids, CalFresh, and In-Home Supportive Services.

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, a beneficiary or enrollee will automatically have their eligibility redetermined based on the new information.

Counties 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. However, eligibility for many applicants and beneficiaries cannot be processed in an automated way. In addition, if an applicant has a unique situation or encounters any glitches during the process, they may need to reach out to a county eligibility worker.

1. Current Data Collection and Reporting. DHCS tracks certain county eligibility and enrollment processes, such as eligibility redeterminations processed by month, but does not report or collect county-level or state-level data related to county call centers that process Medi-Cal eligibility. For instance, the state doesn't know how many calls counties receive, nor how long applicants or beneficiaries wait, on average, when they contact a county for assistance.
2. Survey Data Indicates Challenges Reaching County Staff. An individual can be disenrolled from Medi-Cal because they are verified as ineligible— for example, if their income is too high. In contrast, a procedural disenrollment from Medi-Cal occurs when someone’s eligibility cannot be verified based on missing documentation or inability to contact the person to gather information. DHCS partnered with the California Health Care Foundation to survey individuals who have been procedurally disenrolled from Medi-Cal during the reinstatement of eligibility determinations following a "pause" on such processes imposed during the COVID-19 Public Health Emergency. The survey sought to identify barriers leading to disenrollments. A recent survey of individuals who were procedurally disenrolled found that, of those who received a renewal form and completed or tried to complete it, 35% said that they called the county but got no answer, were on hold too long, or got disconnected. The survey also found that Hispanic respondents were significantly more likely to experience challenges as compared to white respondents. A separate "secret shopper" survey, commissioned by The Children's Partnership to examine county Medi-Cal call lines in more than 30 counties, found callers were on hold for an average of 55 minutes across the counties measured. Average wait time in Kern, Fresno, and Sacramento counties exceeded 90 minutes.

According to the Author

For years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and disconnected calls. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements allowing people to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. This bill would require DHCS to collect and report county call center data to enhance accountability for the provision of customer service over the phone, which counties are legally mandated to provide.

Arguments in Support

Cosponsors Western Center on Law & Poverty and Coalition of California Welfare Rights Organizations write that people are struggling to reach county workers by phone and wait times can exceed five hours. Meanwhile, Californians are losing their health coverage. Legal Services of Northern California gives an example of one person in Santa Cruz who spent four months trying to disenroll from Medi-Cal when her income went up so that she could enroll in Covered California. In another example, a couple submitted their renewal packet but were still disenrolled. While trying to contact an eligibility worker, one of them had to delay an eye surgery and the other incurred over $1,000 in medical debt after an emergency room visit. The Community Clinic Association of Los Angeles County writes in support that enrollment counselors and health navigators that work in their member clinics have also struggled with wait times, disconnects and other challenges reaching county eligibility workers by phone.

Arguments in Opposition Unless Amended

The California Welfare Directors Association (CWDA) opposes this bill unless amended, expressing concerns about the technical ability of counties to collect data specified by the bill, concerns about the comparability of metrics as applied to different call center models, and the potential impact on other programs like CalFresh. CWDA previously expressed concerns about a prior version of the bill that would have required DHCS to impose customer service standards on the counties, but this point of opposition is no longer relevant since the bill has since been narrowed to remove this provision.

FISCAL COMMENTS

According to the Assembly Appropriations Committee:

Total costs potentially in the low to mid-millions of dollars (50% General Fund (GF), 50% federal funds (FF)) in fiscal year (FY) 2025-26 and low millions (50% (GF), 50% (FF)) in FY 2026-27 and ongoing, as follows (costs are 50% GF, 50% FF):

1. Costs of approximately $1.3 million (50% (GF), 50% (FF)) in FY 2025-26 and annually thereafter for eight staff at DHCS to perform call center monitoring activities, work with counties, and provide data support.
2. Annual, ongoing county costs potentially in the low to mid-millions of dollars, including staffing for up to 53 full-time equivalent positions statewide to perform additional duties, such as collecting statistical data from systems-linked call centers (50% (GF), 50% (FF)).
3. Unquantified costs for equipment, software licenses and maintenance agreements.

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.

VOTES

SENATE FLOOR: 39-0-1

YES: Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen

ASM HEALTH: 15-0-1

YES: Bonta, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ABS, ABST OR NV: Waldron

ASM APPROPRIATIONS: 11-0-4

YES: Wicks, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Villapudua

ABS, ABST OR NV: Sanchez, Dixon, Jim Patterson, Ta

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0004093

Date of Hearing: July 2, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

SBPCA Bill Id:SB 1289

Author:(Roth) – As Amended Ver:June 6, 2024

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

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to establish minimum statewide standards for the assistance a county call center provides to applicants for Medi-Cal coverage.

Specifically, this bill:

1. Requires DHCS to establish minimum statewide standards for the assistance a county call center provides to applicants or beneficiaries (collectively, applicants) applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. Requires the standards to take into account difficulties applicants or beneficiaries face in communicating with county agencies during regular business hours.
2. Requires DHCS to seek input from stakeholders, including counties, representatives of employee organizations representing county eligibility workers, and consumer advocates, before establishing standards.
3. Requires the standards be promulgated in regulation by July 1, 2026, and be consistent with standards for other call centers operated by or for DHCS and any applicable federal reporting requirements.
4. Requires a county with a call center to collect and submit to DHCS, by April 1, 2025, and each quarter thereafter, specified call-center data metrics.
5. Requires DHCS to prepare and post on its website, beginning May 15, 2025, quarterly call center data reports that identify challenges and targets or standards for improvement.

FISCAL EFFECT:

DHCS estimates total costs of $6.3 million total funds (TF) ($3.2 million General Fund (GF), $3.2 million federal funds (FF)) in fiscal year (FY) 2025-26 and $4.3 million TF ($2.1 million GF, $2.1 million FF) in FY 2026-27 and ongoing, as follows (costs are 50% GF, 50% FF):

• FY 2025-26 costs of $2 million TF, one-time, for a contractor with industry experience and field expertise to provide technical assistance on industry standards for call centers and serve as a resource as DHCS begins county engagement.
• Costs of $1.34 million TF in FY 2025-26 and $1.27 million in FY 2026-27 and annually thereafter for eight staff at DHCS to perform call center monitoring activities, work with counties, and provide data support.
• Annual, ongoing county costs of approximately $3 million TF, including staffing for up to 53 full-time equivalent positions statewide to perform additional duties, such as collecting statistical data from systems-linked call centers.
• Unquantified costs for equipment, software licenses and maintenance agreements.

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:

1. Purpose. This bill is sponsored by the Coalition of California Welfare Rights Organizations and Western Center on Law & Poverty. According to the author:

For years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and call disconnects. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements that people be allowed to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. When Medi-Cal recipients who lost their Medi-Cal during this recent renewal effort were surveyed, 31% who tried to complete their renewal responded that they called their county but got no answer, were on hold too long, or got disconnected. This bill would require the Department of Health Care Services to develop minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients, and to collect and report county call center data.

1. Background.
   
   Medi-Cal Eligibility Determination. In the Medi-Cal program, counties are responsible for eligibility and enrollment functions, including determining individuals’ initial eligibility to enroll in the program, maintaining accurate records on individuals’ ongoing eligibility, and administering regular eligibility redeterminations.
   
   An individual who a county determined to be eligible and is enrolled in Medi-Cal must have their eligibility redetermined every 12 months to retain coverage for the next year. If new information that affects the individual’s eligibility becomes available to the county during the 12-month period, the county must redetermine the enrollee’s eligibility based on the new information.
   
   DHCS tracks certain county eligibility and enrollment processes, such as eligibility redeterminations processed by month, but does not report or collect county-level or state-level data related to county call centers. For instance, the state does not know how many calls counties receive, nor how long an applicant or beneficiary waits, on average, when they contact a county for assistance.
   
   County Challenges with Medi-Cal Eligibility Determination. According to information provided by the author, even prior to the COVID-19 pandemic, Medi-Cal enrollees had difficulty accessing county eligibility workers by phone, despite state law guaranteeing the right to apply for or renew Medi-Cal by phone. During the COVID-19 pandemic, many counties had trouble retaining staff, and workforce shortages continue. However, due to federal COVID-19 public health emergency requirements, Medi-Cal redeterminations were suspended until the public health emergency ended. In April 2023, counties were required to resume Medi-Cal redeterminations for the first time since 2020. As a result, many Medi-Cal enrollees have been trying to reach their counties to give information needed to keep their Medi-Cal coverage, in addition to new requests to apply for Medi-Cal or to resolve problems with their coverage. As a result, in some places, county call center systems are not working at all. Medi-Cal enrollees and their representatives report hours-long waits, automatic disconnects, messages to call back later, phone tree options with dead ends, and callback features that don’t call back, resulting in some eligible people losing Medi-Cal coverage and access to health care.
2. Oppose Unless Amended. The County Welfare Directors Association of California (CWDA) opposes this bill unless amended to address concerns about cost, staffing constraints, other priorities, and technical ability to collect data specified by the bill and comply with this bill’s requirements. First, CWDA requests that compliance with this bill be contingent on funding and that necessary staffing levels be calculated using a specified methodology. CWDA points out counties have different needs and capabilities, such as lines in different languages and the availability of different functionality, which would make apples-to-apples comparisons as well as compliance difficult, and therefore asks that the metrics be provided only “where available.” CWDA also requests the bill exempt call centers operated under the provisions of the “Quick Sort Transfer” warm handoff process between counties and Covered California, which already has standards and reporting metrics. Finally, CWDA requests that the implementation date reflect the necessary lead time for hiring, training, labor consultation, and other needed adjustments. Additionally, CWDA notes the costs are unknown until standards are established, and points out applying standards for Medi-Cal would also have an unintended consequence of imposing these standards for CalFresh and potentially CalWORKS.
3. Related Legislation. AB 2956 (Boerner) makes changes to Medi-Cal redetermination procedures, including the requirement that counties collect and submit to DHCS call center data metrics. AB 2956 was held on this committee’s suspense file.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: June 4, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

SBPCA Bill Id:SB 1289

Author:(Roth) – As Amended Ver:April 29, 2024

SENATE VOTE: 39-0

SUBJECT: Medi-Cal: call centers: standards and data.

SUMMARY: Requires Department of Health Care Services (DHCS) to collect specified data and establish customer service standards for county call centers that process Medi-Cal eligibility and enrollment. Specifically, this bill:

1. Requires DHCS to establish statewide minimum standards for assistance provided by a county’s call center to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. Requires standards to take into account challenges that Medi-Cal applicants or beneficiaries face in communicating with county agencies during regular business hours.
2. Requires DHCS to seek input from stakeholders, including, but not limited to, counties, representatives of employee organizations representing county eligibility workers, and consumer advocates, prior to establishing standards.
3. Requires the standards be promulgated in regulation by July 1, 2026, and be consistent with standards for other call centers operated by, or under contract with, DHCS and any applicable federal reporting requirements.
4. Requires, by April 1, 2025, and each quarter thereafter, a county with a call center to collect and submit to DHCS specified call-center data metrics.
5. Requires DHCS to prepare quarterly reports on call center data that also identify challenges and targets or standards for improvement; and requires the initial report by May 15, 2025.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [Welfare and Institutions Code (WIC) §14000 et seq.]
   
2. Makes Medi-Cal eligibility and enrollment functions a county function and responsibility, subject to the direction, authority, and regulations of DHCS. [WIC §14001.11]
3. Gives individuals the option to apply for Medi-Cal in person, by mail, online, by telephone, or by other commonly available electronic means. Requires renewal procedures to include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means. [WIC §15926]
4. Requires a county to perform redeterminations of eligibility for Medi-Cal recipients every 12 months and to promptly redetermine eligibility whenever the county receives information about changes in a recipient’s circumstances that may affect eligibility for Medi-Cal benefits. Allows a recipient to provide information regarding a change in circumstances or requested by the county over the telephone. Allows recipients to provide signatures over the telephone for forms that are required to be signed. [WIC §14005.37]
   
5. Requires a county to notify a Medi-Cal recipient when their Medi-Cal eligibility worker changes and to include in the notice the worker’s telephone number and hours during which the eligibility workers may be contacted. [WIC §14005.33]
6. Requires DHCS to provide assistance over the telephone to any applicant or recipient that requests help with the application or redetermination process, subject to certain conditions. [WIC §14000.7]
7. Establishes the CalFresh program to provide food benefits under the federal Supplemental Nutrition Assistance Program. [WIC §18900 et seq.]
8. Requires counties to ensure that Medi-Cal applicants who also may be eligible for CalFresh, are screened and given the opportunity to apply at the same time they are applying for Medi-Cal or submitting information for the renewal process, and ensure the same staff that receive Medi-Cal and CalFresh applications conduct the eligibility determination functions needed to determine eligibility or ineligibility for CalFresh. [WIC §18918.1]
   

FISCAL EFFECT: According to the Senate Committee on Appropriations:

1. Unknown, ongoing costs, likely hundreds of thousands, for DHCS for state administration (General Fund (GF) and federal funds).
2. Unknown, ongoing costs to counties for the collection of data. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, for years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and disconnected calls. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements allowing people to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. When Medi-Cal recipients who lost their coverage during this recent renewal effort were surveyed, one third who tried to complete their renewal responded that they called their county but got no answer, were on hold too long, or got disconnected. This bill would require DHCS to develop minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients, and to collect and report county call center data.
2. BACKGROUND.
   1. Basic Medi-Cal Eligibility Redetermination Requirements and Processes. Medicaid is a state-federal program, and states have a variety of options in program design as long as they meet federal requirements. In California’s Medi-Cal program, counties are responsible for eligibility and enrollment functions. This includes things like determining individuals’ initial eligibility to enroll in the program, maintaining accurate records on individuals’ ongoing eligibility, and administering regular eligibility redeterminations. Counties also are responsible for similar functions in major human services programs, including California Work Opportunity and Responsibility to Kids (CalWORKs), CalFresh, and In-Home Supportive Services.

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, a beneficiary or enrollee will automatically have their eligibility redetermined based on the new information.

Counties 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. However, eligibility for many applicants and beneficiaries cannot be processed in an automated way. In addition, if an applicant has a unique situation or encounters any glitches during the process, they may need to reach out to a county eligibility worker.

• 1. Current Data Collection and Reporting. DHCS tracks certain county eligibility and enrollment processes, such as eligibility redeterminations processed by month, but does not report or collect county-level or state-level data related to county call centers. For instance, the state doesn’t know how many calls counties receive, nor how long applicants or beneficiaries wait, on average, when they contact a county for assistance.

According to DHCS, the state only reports call center volume, average wait time, and average abandonment rate to the Centers for Medicare & Medicaid Services from the following call centers:

• • 1. Covered California regional call centers;
    2. Health Care Options, a contracted Medi-Cal managed care plan enrollment call center; and,
    3. DHCS provider and member billing customer service line.
       
  1. Public Health Emergency (PHE) Eligibility Processes and “Unwinding.” The federal government required states to pause redeterminations of Medi-Cal eligibility through the COVID-19 PHE, keeping most people on the program rolls. Beginning in 2023, California began resuming redeterminations. This resumption of redetermination processes is colloquially called the “PHE Unwinding.” 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 were not familiar with required paperwork and processes.
     According to DHCS, there have been anecdotal reports of long wait times during the PHE Unwinding. DHCS and counties have been working together to address these challenges. For instance, some counties have implemented interactive voice response to local navigators at their local site. DHCS has emphasized there is autonomy in decision-making at the county level to best allocate available resources to meet the needs.
  2. May Revision Proposals. To balance the 2024-25 budget, a number of budget solutions have been proposed in the Governor’s May Revision to the 2024-25 Budget. Two proposals are particularly relevant to this bill:
     1. County Administration Funding Freeze. Counties receive a Cost of Living Adjustment annually to the administrative funding they receive from the state to process Medi-Cal eligibility and enrollment functions. The May Revision proposes to freeze county administration funding at current levels to save $20.4 million GF in fiscal year 2024-25 and $42.0 million in 2025-26, as well as additional GF resources in future fiscal years. The impact of this freeze is unknown, but it would likely reduce resources available to improve customer service levels.
     2. Health Enrollment Navigators Funding Elimination. The May Revision proposes to eliminate the last year of funding for a limited-term Health Enrollment Navigators program, including $16 million in fiscal year 2024-25 for grants and $8 million for grants specific to navigators in clinics. According to DHCS, these efforts fund county, clinic, and community-based organization entities to engage in eight specified activities for hard-to-reach target populations to enroll, retain, and assist Medi-Cal applicants and current Medi-Cal members. Although county eligibility staff are primarily responsible for Medi-Cal eligibility and enrollment functions, navigators have in recent years reduced some pressure on county administrative staff by helping assist applicants and beneficiaries, including in culturally and linguistically concordant ways.
  3. Survey Data Indicates Challenges Reaching County Staff. An individual can be disenrolled from Medi-Cal because they are verified as ineligible, for example, their income is too high. In contrast, a procedural disenrollment from Medi-Cal occurs when someone cannot be verified eligible for the program based on missing documentation or inability to contact the person to gather information. DHCS has partnered with the California Health Care Foundation to survey individuals who have been procedurally disenrolled from Medi-Cal during the PHE unwinding period in order to identify barriers leading to disenrollments. A recent survey of individuals who were procedurally disenrolled found that, of those who received a renewal form and completed or tried to complete it, 35% said that they called the county but got no answer, were on hold too long, or got disconnected. The survey also found that Hispanic respondents were significantly more likely to experience challenges as compared to white respondents.

1. SUPPORT. Cosponsors Western Center on Law & Poverty and Coalition of California Welfare Rights Organizations write that people are struggling to reach county workers by phone and wait times can exceed five hours. Even in counties with shorter wait times, actual processing times are much longer. For instance, Los Angeles County averages a 30-minute wait time with a ticket system that workers process later. At any time, approximately 40,000 of those tickets are languishing in queue, waiting to be processed. Meanwhile, Californians are losing their health coverage. Legal Services of Northern California gives an example of one person in Santa Cruz who spent four months trying to disenroll from Medi-Cal when her income went up so that she could enroll in Covered California. In another example, a couple submitted their renewal packet but were still disenrolled. While trying to contact an eligibility worker, one of them had to delay an eye surgery and the other incurred over $1,000 in medical debt after an emergency room visit. The Community Clinic Association of Los Angeles County writes in support that enrollment counselors and health navigators that work in their member clinics have also struggled with wait times, disconnects and other challenges reaching county eligibility workers quickly by phone.
2. OPPOSITION UNLESS AMENDED. The California Welfare Directors Association (CWDA) opposes this bill unless amended to address their concerns about the imposition of standards in light of cost, staffing constraints, other priorities, and technical ability to collect data specified by the bill and comply with this bill’s requirements. CWDA indicates they appreciate the April 29, 2024, amendments to this bill, but they express a number of remaining concerns and requests. First, CWDA requests that compliance with this bill be contingent on funding and that necessary staffing levels be calculated using a specified methodology. CWDA points out counties have different needs and capabilities, such as lines in different languages and the availability of different functionality, which would make apples-to-apples comparisons as well as compliance difficult, and therefore asks that the metrics be provided only “where available.” CWDA also requests the bill exempt call centers operated under the provisions of the “Quick Sort Transfer” warm handoff process between counties and Covered California, which already have standards and reporting metrics. Finally, CWDA requests that the implementation date reflect the necessary lead time for hiring, training, labor consultation, and other needed adjustments. Additionally, CWDA notes the costs are unknown until standards are established, and points out applying standards for Medi-Cal would also have an unintended consequence of imposing these standards for CalFresh and potentially CalWORKS.
3. RELATED LEGISLATION. AB 2956 (Boerner) makes various changes to Medi-Cal redetermination procedures including the requirement that counties collect and submit to DHCS call center data metrics. AB 2956 was held on the Suspense File of the Assembly Appropriations Committee.
4. PREVIOUS LEGISLATION.
   1. AB 1X 1 (John A. Pérez), Chapter 3, Statutes of 2013, codified the Patient Protection and Affordable Care Act’s (ACA’s) Medi-Cal redetermination requirements, among other things.
   2. AB 1296 (Bonilla), Chapter 641, Statutes of 2011, codified the ACA’s rules for Medi-Cal and Covered California applications.
5. POLICY COMMENTS. This bill addresses an important gap in the state’s ability to collect and report on data on a critical customer service function—the ability to reach a Medi-Cal county eligibility worker by phone. Although counties administer these functions, DHCS is the single state agency responsible for Medi-Cal administration. The state’s choice to make eligibility a local function does not lessen the state’s responsibility to monitor and ensure a reasonable level of customer service. In addition, other call centers, such as those administered by Covered California, do report such data.
   On the other hand, counties raise legitimate questions about resources needed to meet standards and the difficulty in imposing one-size-fits-all standards on a system that varies significantly among counties. The author may wish to engage further with DHCS and counties and consider whether it is appropriate to approach improvements in a stepwise fashion. This could look like, for instance, first initiating data collection and, later, imposing standards based on a consideration of whether meeting industry standards would require more resources.
   
   In addition, this bill is prescriptive in the data that must be reported by counties, including call volume, average call wait times by language, call answer rate, call abandonment rate, maximum wait times, total handle time, disconnects, calls resolved by interactive voice response, callbacks, and calls disconnected during high-call-volume periods. The author may wish to consider whether there is benefit to providing DHCS more flexibility to define specific metrics that must be reported, in consultation with stakeholders and based on analysis of feasibility and review of consistency with other call centers, as long as important aspects of the customer service experience are captured.
6. AMENDMENTS. The author and Committee have agreed to amend the bill streamline the quarterly reporting. Per this change, quarterly reporting will only include the data metrics, while the standards, targets, and challenges will be discussed through the stakeholder process identified in the bill’s other provisions.

Specifically, Section 1, Welfare and Institutions Code Section 14000.8 (b)(2) will be amended as follows:

(2) The department shall prepare a report, excluding any personally identifiable information, on call-center data as described in paragraph (1), identifying challenges and targets or standards for improvement. The department shall post the report on the department’s internet website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter. The initial report on call-center data described in paragraph (1) shall be due on May 15, 2025.

REGISTERED SUPPORT / OPPOSITION:

Support

Western Center on Law & Poverty (cosponsor)
Coalition of California Welfare Rights Organizations (cosponsor)
Asian Americans Advancing Justice-southern California
Asian Resources, Inc.
Bet Tzedek Legal Services
California Association of Food Banks
CANHR
Children Now
Children's Partnership
Community Clinic Association of Los Angeles County (CCALAC)
Community Legal Aid SoCal
CPCA Advocates
Grace Institute - End Child Poverty in CA
Justice in Aging
Latino Coalition for a Healthy California
Legal Services of Northern California
Maternal and Child Health Access
National Health Law Program
Northeast Valley Health Corporation
Parent Engagement Academy
Second Harvest Food Bank of Orange County
South Asian Network
Venice Family Clinic

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 1289

Author: Roth (D)

Amended: 4/29/24

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 4/24/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/16/24

AYES: Caballero, Jones, Ashby, Becker, Bradford, Seyarto, Wahab

SUBJECT: Medi-Cal: call centers: standards and data

SOURCE: Coalition of California Welfare Rights Organizations

Western Center on Law & Poverty

DIGEST:

This bill requires the Department of Health Care Services (DHCS) to establish statewide minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients. Requires counties operating call centers to collect and submit call-center metrics and DHCS to report on those metrics on a quarterly basis on its website.

ANALYSIS: Existing federal law requires states to use a single, streamlined application that may be filed online, in person, by mail, or by telephone to apply for enrollment through the state’s Medicaid, CHIP, or health subsidy program. [42 USC §18083]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000 et seq.]
2. Delegates to the county of residence the responsibility for Medi-Cal eligibility determinations and ongoing case management. [WIC §14015.5]
3. Gives individuals the option to apply for Medi-Cal in person, by mail, online, by telephone, or by other commonly available electronic means. Requires renewal procedures to include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means. [WIC §15926]
4. Requires a county to perform redeterminations of eligibility for Medi-Cal recipients every 12 months and to promptly redetermine eligibility whenever the county receives information about changes in a recipient’s circumstances that may affect eligibility for Medi-Cal benefits. Allows a recipient to provide information regarding a change in circumstances or requested by the county over the telephone. Allows recipients to provide signatures over the telephone for forms that are required to be signed. [WIC §14005.37]
5. Requires a county to notify a Medi-Cal recipient when their Medi-Cal eligibility worker changes and to include in the notice the worker’s telephone number and hours during which the eligibility workers may be contacted. [WIC §14005.33]
6. Requires DHCS to provide assistance over the telephone to any applicant or recipient that requests help with the application or redetermination process. [WIC §14000.7]

This bill:

1. Requires DHCS to establish statewide minimum standards for assistance provided by a county’s call center to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. Requires the standards to take into account challenges that Medi-Cal applicants or beneficiaries face in communicating with county agencies during regular business hours.
2. Requires DHCS to seek input from stakeholders, including counties, representatives of employee organizations representing county eligibility workers, and consumer advocates before establishing the standards described in 1).
3. Requires the standards described in paragraph 1) to be promulgated in regulation by July 1, 2026, and be consistent with standards for other call centers operated by, or under contract with, DHCS and any applicable federal reporting requirements.
4. Requires a county with a call center for Medi-Cal applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage to collect and submit to the DHCS call-center data metrics, including, call volume, average call wait times by language, call answer rate, call abandonment rate, maximum wait times, total handle time, disconnects, calls resolved by interactive voice response, callbacks, and calls disconnected during high-call-volume periods starting April 1, 2025 and each quarter thereafter.
5. Requires DHCS to prepare a report, excluding any personally identifiable information, on call-center data described in 4) above identifying challenges and targets or standards for improvement. Requires DHCS to post the report on its website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter starting May 15, 2025.
6. Permits reimbursement to local agencies for costs if the Commission on State Mandates determine that this act contains costs mandated by the state.

Comments

1. Author’s statement. According to the author, for years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and call disconnects. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements allowing people to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. When Medi-Cal recipients who lost their coverage during this recent renewal effort were surveyed, one third who tried to complete their renewal responded that they called their county but got no answer, were on hold too long, or got disconnected. This bill would require DHCS to develop minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients, and to collect and report county call center data.
2. Medi-Cal eligibility and “no wrong door.” The Affordable Care Act required states to create a single-streamlined application for all insurance affordability programs (Medicaid and the Children’s Health Insurance Program, which are joined as Medi-Cal in California, and the state health exchange, Covered California) that could be submitted in person, online, via mail, or by telephone. In California, applications for the Medi-Cal program are processed by county eligibility workers, thus in order to apply by phone, an applicant needs to call the county. Federal and state law also specify that applicants may call the county to provide additional information if they get a notice that information is missing from their application. Allowing for telephone access is part of a “no wrong door” philosophy that ensures that the Medi-Cal program is accessible to all who are eligible, including those with low vision, low literacy, lack of access to computers, or any other barriers that might make filling out a paper or online application difficult.
3. Medi-Cal renewals and the public health emergency unwinding. Medi-Cal recipients are required to report to the county any changes in circumstances that might affect their eligibility, such as a change in income or household size. They are also required to have their eligibility redetermined every 12 months if no other changes in circumstances have occurred. Just as applicants have the right to apply for the program by phone, Medi-Cal recipients can also provide information needed to complete redetermination over the phone. Counties are required to first do an ex parte review of an individual’s Medi-Cal case to determine if the county already has enough information based on state and federal databases to renew an individual, and if not, ask the individual only for the information that is needed to complete an eligibility determination. If there is missing information, the individual would need to provide that to the county, either by phone, or by sending the information in. Sometimes an individual need only provide an explanation, such as in cases where income one month is not expected to reflect what that individual’s annual income would be because the individual no longer has the job or had their hours cut.

California is currently redetermining all Medi-Cal recipients following years of continuous eligibility for everyone during the COVID-19 public health emergency, regardless of changes in circumstances. As a result, many people have lost Medi-Cal due to procedural terminations (i.e., a county was unable to determine whether the individual was actually eligible due to missing information). Given the long wait times that recipients are experiencing when trying to contact their county by phone, DHCS recently released guidance to county welfare directors encouraging the use of interactive voice response (IVR) as part of their call-in process to include messaging about renewal assistance available within the county. DHCS’s guidance suggests that the IVR messaging direct callers to an outside community-based organization, health plan, or navigator. It should be noted that while these other entities can answer basic questions about the Medi-Cal program, they cannot redetermine eligibility.

DHCS has partnered with the California Health Care Foundation to survey individuals who have been procedurally disenrolled from Medi-Cal during this continuous coverage unwinding period in order to identify barriers that are causing these disenrollments. The latest survey of individuals who were procedurally disenrolled on January 1, 2024 found that of those that received a renewal form and completed or tried to complete it, 35% said that they called the county but got no answer, were on hold too long, or got disconnected. The survey also found that Hispanic respondents were significantly more likely to experience challenges as compared to White respondents.

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

According to the Senate Appropriations Committee:

• Unknown, ongoing costs, likely hundreds of thousands, for the DHCS for state administration (General Fund and federal funds).
• Unknown, ongoing costs to counties for the collection of data. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

SUPPORT: (Verified 5/15/24)

Coalition of California Welfare Rights Organizations (co-source)

Western Center on Law & Poverty (co-source)

Asian Americans Advancing Justice Southern California

Asian Resources, Inc.

Bet Tzedek Legal Services

California Association of Food Banks

California Advocates for Nursing Reform

California Primary Care Association

Community Clinic Association of Los Angeles County

Community Legal Aid SoCal

Grace Institute

Justice in Aging

Latino Coalition for a Health California

Legal Services of Northern California

Maternal and Child Health Access

National Health Law Program

Northeast Valley Health Corporation

Second Harvest Food Bank of Orange County

Venice Family Clinic

OPPOSITION: (Verified 5/15/24)

None received

ARGUMENTS IN SUPPORT: Co-sponsors Western Center on Law & Poverty and Coalition of California Welfare Rights Organizations write that people are struggling to reach county workers by phone and wait times can exceed five hours. Even in counties with shorter wait times, actual processing times are much longer. For instance, Los Angeles County averages a 30-minute wait time with a ticket system that workers process later. At any time, approximately 40,000 of those tickets are languishing in queue, waiting to be processed. Meanwhile, Californians are losing their health coverage. Legal Services of Northern California gives an example of one person in Santa Cruz who spent four months trying to disenroll from Medi-Cal when her income went up so that she could enroll in Covered California. In another example, a couple submitted their renewal packet but were still disenrolled. While trying to contact an eligibility worker, one of them had to delay an eye surgery and the other incurred over $1,000 in medical debt after an emergency room visit.

Supporter the Community Clinic Association of Los Angeles County writes that over the past 10 year, enrollment counselors and health navigators that work in their member clinics have struggled with wait times, disconnects and other challenges reaching county eligibility workers quickly by phone. Enrollment staff typically spend anywhere from 45 minutes to 3 hours waiting to connect and working to resolve issues. Generally, patients need to be on the line as well, adding further to the burden. Like most health care entities, health centers struggle with staff bandwidth, and cannot have employees spend hours of their workday waiting on hold. If patients simply cannot spend the needed time waiting, coverage can lapse, and patients cannot get the services, referrals, or medications they were seeking.

Prepared by: Jen Flory / HEALTH / (916) 651-4111

5/17/24 17:19:27

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SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 1289 (Roth) - Medi-Cal: call centers: standards and data

Bill Summary:

SB 1289 would require the Department of Health Care Services (DHCS) to establish statewide minimum standards for assistance provided by a county’s call center to Medi-Cal applicants and recipients; and require a county with a call center to collect and submit call-center metrics, as specified.

Fiscal Impact:

• Unknown, ongoing costs, likely hundreds of thousands, for the DHCS for state administration (General Fund and federal funds).
• Unknown, ongoing costs to counties for the collection of data. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

Background:

The Medi-Cal program, administered by DHCS, provides health coverage to eligible low-income individuals. Counties are responsible for Medi-Cal eligibility determinations and ongoing case management. Current law gives individuals the option to apply for Medi-Cal in person, by mail, online, by telephone, or by other commonly available electronic means. Current law also requires renewal procedures to include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means.

Counties must perform redeterminations of eligibility for Medi-Cal recipients every 12 months and must promptly redetermine eligibility whenever the county receives information about changes in a recipient’s circumstances that may affect eligibility for Medi-Cal benefits. A recipient may provide information regarding a change in circumstances or requested by the county over the telephone. A recipient may also provide signatures over the telephone for forms that are required to be signed. Current law requires a county to notify a Medi-Cal recipient when their Medi-Cal eligibility worker changes and to include in the notice the worker’s telephone number and hours during which the eligibility workers may be contacted.

Proposed Law:

Specific provisions of the bill would:

• Require DHCS to establish statewide minimum standards for assistance provided by a county’s call center to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage.
• Require a county with a call center for Medi-Cal applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage to collect and submit quarterly to DHCS, call-center data metrics; and specify that the data include, but not be limited to, call volume, average call wait times by language, call answer rate, call abandonment rate, maximum wait times, total handle time, disconnects, calls resolved by interactive voice response, callbacks, and calls disconnected during high-call-volume periods.
• Require DHCS to prepare a report on call-center data, identifying challenges and targets or standards for improvement; and require DHCS to post the report on its internet website on a quarterly basis.

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SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: SB 1289

SUBJECT: Medi-Cal: county call centers: data

SUMMARY:

Requires the Department of Health Care Services (DHCS) to establish statewide minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients. Requires counties to collect and submit call-center metrics and DHCS to report on those metrics on a quarterly basis on its website. Allows for alternative standards and metrics for counties not operating call centers.

Existing federal law: Requires states to use a single, streamlined application that may be filed online, in person, by mail, or by telephone to apply for enrollment through the state’s Medicaid, CHIP, or health subsidy program. [42 USC §18083]

Existing state law

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000 et seq.]
2. Delegates to the county of residence the responsibility for Medi-Cal eligibility determinations and ongoing case management. [WIC §14015.5]
3. Gives individuals the option to apply for Medi-Cal in person, by mail, online, by telephone, or by other commonly available electronic means. Requires renewal procedures to include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means. [WIC §15926]
4. Requires a county to perform redeterminations of eligibility for Medi-Cal recipients every 12 months and to promptly redetermine eligibility whenever the county receives information about changes in a recipient’s circumstances that may affect eligibility for Medi-Cal benefits. Allows a recipient to provide information regarding a change in circumstances or requested by the county over the telephone. Allows recipients to provide signatures over the telephone for forms that are required to be signed. [WIC §14005.37]
5. Requires a county to notify a Medi-Cal recipient when their Medi-Cal eligibility worker changes and to include in the notice the worker’s telephone number and hours during which the eligibility workers may be contacted. [WIC §14005.33]
6. Requires DHCS to provide assistance over the telephone to any applicant or recipient that requests help with the application or redetermination process. [WIC §14000.7]

This bill:

1. Requires DHCS to establish statewide minimum standards for assistance provided by county call centers to applicants or beneficiaries applying for, renewing, or requesting help in obtaining or maintaining Medi-Cal coverage. Requires the standards to take into account challenges that Medi-Cal applicants or beneficiaries face in communicating with county agencies during regular business hours.
2. Requires the standards described in paragraph 1) to be promulgated in regulation by July 1, 2026, and be consistent with standards for other call centers operated by, or under contract with, DHCS and any applicable federal reporting requirements.
3. Allows DHCS to develop alternate standards for a county that does not operate a call center for Medi-Cal applicants and beneficiaries in order to ensure that applicants and beneficiaries can timely give and receive information about their Medi-Cal eligibility.
4. Requires a county to collect and submit to the DHCS call-center data metrics, including, call volume, average call wait times by language, call answer rate, call abandonment rate, maximum wait times, total handle time, disconnects, calls resolved by interactive voice response, callbacks, and calls disconnected during high-call-volume periods starting April 1, 2025 and each quarter thereafter.
5. Requires a county that does not operate a call center for Medi-Cal applicants and recipients to collect and submit DHCS-approved alternate metrics by July 1, 2025 and each quarter thereafter.
6. Requires DHCS to prepare a report, excluding any personally identifiable information, on county call data identifying challenges and targets or standards for improvement. Requires DHCS to post the report on its website on a quarterly basis no later than 45 calendar days after the conclusion of each quarter starting May 15, 2025.

FISCAL EFFECT:

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

COMMENTS:

1. Author’s statement. According to the author, for years, people on Medi-Cal have struggled to reach county eligibility workers by phone due to long wait times and call disconnects. When they cannot get through by phone, they often cannot complete a Medi-Cal application or renewal, reinstate their Medi-Cal, or make other corrections, despite state and federal law requirements allowing people to do these things over the phone. This situation predates the COVID-19 pandemic, but has gotten worse due to county workforce shortages and the federal requirement to renew everyone’s Medi-Cal for the first time since the pandemic began. When Medi-Cal recipients who lost their coverage during this recent renewal effort were surveyed, one third who tried to complete their renewal responded that they called their county but got no answer, were on hold too long, or got disconnected. This bill would require DHCS to develop minimum standards for assistance provided by county call centers to Medi-Cal applicants and recipients, and to collect and report county call center data.
2. Medi-Cal eligibility and “no wrong door.” The Affordable Care Act required states to create a single-streamlined application for all insurance affordability programs (Medicaid and the Children’s Health Insurance Program, which are joined as Medi-Cal in California, and the state health exchange, Covered California) that could be submitted in person, online, via mail, or by telephone. In California, applications for the Medi-Cal program are processed by county eligibility workers, thus in order to apply by phone, an applicant needs to call the county. Federal and state law also specify that applicants may call the county to provide additional information if they get a notice that information is missing from their application. Allowing for telephone access is part of a “no wrong door” philosophy that ensures that the Medi-Cal program is accessible to all who are eligible, including those with low vision, low literacy, lack of access to computers, or any other barriers that might make filling out a paper or online application difficult.
3. Medi-Cal renewals and the public health emergency unwinding. Medi-Cal recipients are required to report to the county any changes in circumstances that might affect their eligibility, such as a change in income or household size. They are also required to have their eligibility redetermined every 12 months if no other changes in circumstances have occurred. Just as applicants have the right to apply for the program by phone, Medi-Cal recipients can also provide information needed to complete redetermination over the phone. Counties are required to first do an ex parte review of an individual’s Medi-Cal case to determine if the county already has enough information based on state and federal databases to renew an individual, and if not, ask the individual only for the information that is needed to complete an eligibility determination. If there is missing information, the individual would need to provide that to the county, either by phone, or by sending the information in. Sometimes an individual need only provide an explanation, such as in cases where income one month is not expected to reflect what that individual’s annual income would be because the individual no longer has the job or had their hours cut.

California is currently redetermining all Medi-Cal recipients following years of continuous eligibility for everyone during the COVID-19 public health emergency, regardless of changes in circumstances. As a result, many people have lost Medi-Cal due to procedural terminations (i.e., a county was unable to determine whether the individual was actually eligible due to missing information). Given the long wait times that recipients are experiencing when trying to contact their county by phone, DHCS recently released guidance to county welfare directors encouraging the use of interactive voice response (IVR) as part of their call-in process to include messaging about renewal assistance available within the county. DHCS’s guidance suggests that the IVR messaging direct callers to an outside community-based organization, health plan, or navigator. It should be noted that while these other entities can answer basic questions about the Medi-Cal program, they cannot redetermine eligibility.

DHCS has partnered with the California Health Care Foundation to survey individuals who have been procedurally disenrolled from Medi-Cal during this continuous coverage unwinding period in order to identify barriers that are causing these disenrollments. The latest survey of individuals who were procedurally disenrolled on January 1, 2024 found that of those that received a renewal form and completed or tried to complete it, 35% said that they called the county but got no answer, were on hold too long, or got disconnected. The survey also found that Hispanic respondents were significantly more likely to experience challenges as compared to White respondents.

1. Related legislation. AB 2956 (Boerner) makes various changes to Medi-Cal redetermination procedures including the requirement that counties collect and submit to DHCS call center data metrics. SB 2956 is in the Assembly Appropriations Committee.
2. Prior legislation. AB 1X-1 (Pérez, Chapter 3, Statutes of 2013) codified the Affordable Care Act’s Medi-Cal redetermination requirements, among other things.

AB 1296 (Bonilla, Chapter 641, Statutes of 2011) codified the Affordable Care Act’s no wrong door rules for Medi-Cal and Covered California applications.

1. Support. Co-sponsors Western Center on Law & Poverty and Coalition of California Welfare Rights Organizations write that people are struggling to reach county workers by phone and wait times can exceed five hours. Even in counties with shorter wait times, actual processing times are much longer. For instance, Los Angeles County averages a 30-minute wait time with a ticket system that workers process later. At any time, approximately 40,000 of those tickets are languishing in queue, waiting to be processed. Meanwhile, Californians are losing their health coverage. Legal Services of Northern California gives an example of one person in Santa Cruz who spent four months trying to disenroll from Medi-Cal when her income went up so that she could enroll in Covered California. In another example, a couple submitted their renewal packet but were still disenrolled. While trying to contact an eligibility worker, one of them had to delay an eye surgery and the other incurred over $1,000 in medical debt after an emergency room visit.

Supporter the Community Clinic Association of Los Angeles County writes that over the past 10 year, enrollment counselors and health navigators that work in their member clinics have struggled with wait times, disconnects and other challenges reaching county eligibility workers quickly by phone. Enrollment staff typically spend anywhere from 45 minutes to 3 hours waiting to connect and working to resolve issues. Generally, patients need to be on the line as well, adding further to the burden. Like most health care entities, health centers struggle with staff bandwidth, and cannot have employees spend hours of their workday waiting on hold. If patients simply cannot spend the needed time waiting, coverage can lapse, and patients cannot get the services, referrals, or medications they were seeking.

1. Oppose unless amended – The County Welfare Directors Association of California write in opposition unless the following changes are made: 1) the scope of the bill be narrowed to only apply to counties that operate call centers; 2) the state be required to work with counties and representatives of employee organizations to develop call center standards; and 3) the call center standards not be applied or enforced in any fiscal year in which full funding is provided by the state to counties to meet whatever standards are ultimately developed. They anticipate significant staffing and workload pressures that would be counterproductive to the overall goal of improving program access.
2. Amendments. The author and committee have agreed to amendments to address the first two issues raised by the County Welfare Directors Association: narrowing the bill to include only counties that operate call centers and requiring DHCS to receive input from stakeholders prior to establishing call center standards.

SUPPORT AND OPPOSITION:

Support: Coalition of California Welfare Rights Organizations (co-sponsor)

Western Center on Law & Poverty (co-sponsor)

Asian Resources, Inc.

Bet Tzedek Legal Services

California Association of Food Banks

California Advocates for Nursing Reform

Community Clinic Association of Los Angeles County

Community Legal Aid SoCal

Justice in Aging

Latino Coalition for a Health California

Legal Services of Northern California

Maternal and Child Health Access

National Health Law Program

Northeast Valley Health Corporation

Western Center on Law and Poverty

Oppose: County Welfare Directors Association of California (unless amended)

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