Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including in-home supportive services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law generally requires a county to redetermine a Medi-Cal beneficiarys eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiarys circumstances that may affect their eligibility for Medi-Cal benefits.

Existing law provides for the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, and disabled persons are provided with supportive services in order to permit them to remain in their own homes. Existing law authorizes certain Medi-Cal beneficiaries to receive IHSS as a covered Medi-Cal benefit.

This bill would, to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized, require an IHSS recipient to be continuously eligible for Medi-Cal for 3 years, if they have a fixed income, and would prohibit a redetermination of Medi-Cal eligibility before 3 years, except as specified. The bill would make the implementation of its provisions contingent upon the department obtaining all necessary federal approvals, the department determining that systems have been programmed to implement these provisions, and the Legislature has appropriated funding to implement these provisions after a determination that ongoing General Fund resources are available to support the ongoing implementation of these provisions. To the extent the bill would increase county duties in administrating the IHSS program, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including in-home supportive services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law generally requires a county to redetermine a Medi-Cal beneficiarys eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiarys circumstances that may affect their eligibility for Medi-Cal benefits.

Existing law provides for the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, and disabled persons are provided with supportive services in order to permit them to remain in their own homes. Existing law authorizes certain Medi-Cal beneficiaries to receive IHSS as a covered Medi-Cal benefit.

This bill would, to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized, require an IHSS recipient to be continuously eligible for Medi-Cal for 3 years, if they have a fixed income, and would prohibit a redetermination of Medi-Cal eligibility before 3 years, except as specified. The bill would make the implementation of its provisions contingent upon the department obtaining all necessary federal approvals, the department determining that systems have been programmed to implement these provisions, and the Legislature has appropriated funding to implement these provisions after a determination that ongoing General Fund resources are available to support the ongoing implementation of these provisions. To the extent the bill would increase county duties in administrating the IHSS program, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including in-home supportive services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law generally requires a county to redetermine a Medi-Cal beneficiarys eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiarys circumstances that may affect their eligibility for Medi-Cal benefits.

Existing law provides for the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, and disabled persons are provided with supportive services in order to permit them to remain in their own homes. Existing law authorizes certain Medi-Cal beneficiaries to receive IHSS as a covered Medi-Cal benefit.

This bill would, to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized, require an IHSS recipient to be continuously eligible for Medi-Cal for 3 years, if they have a fixed income, and would prohibit a redetermination of Medi-Cal eligibility before 3 years, except as specified. The bill would make the implementation of its provisions contingent upon the department obtaining all necessary federal approvals, the department determining that systems have been programmed to implement these provisions, and the Legislature has appropriated funding to implement these provisions after a determination that ongoing General Fund resources are available to support the ongoing implementation of these provisions. To the extent the bill would increase county duties in administrating the IHSS program, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including in-home supportive services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law generally requires a county to redetermine a Medi-Cal beneficiarys eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiarys circumstances that may affect their eligibility for Medi-Cal benefits.

Existing law provides for the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, and disabled persons are provided with supportive services in order to permit them to remain in their own homes. Existing law authorizes certain Medi-Cal beneficiaries to receive IHSS as a covered Medi-Cal benefit.

This bill would, to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized, require an IHSS recipient to be continuously eligible for Medi-Cal for 3 years, and would prohibit a redetermination of Medi-Cal eligibility before 3 years, except as specified. The bill would make the implementation of its provisions contingent upon the department obtaining all necessary federal approvals, the department determining that systems have been programmed to implement these provisions, and the Legislature has appropriated funding to implement these provisions after a determination that ongoing General Fund resources are available to support the ongoing implementation of these provisions. To the extent the bill would increase county duties in administrating the IHSS program, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 1355 (Wahab) - Medi-Cal: in-home supportive services: redetermination

Bill Summary:

SB 1355 would prohibit subjecting a Medi-Cal recipient on a fixed income who is receiving In-Home Supportive Services (IHSS) to Medi-Cal eligibility redetermination before three years, except in specified circumstances.

Fiscal Impact:

• Unknown, potentially significant ongoing costs, for increased Medi-Cal caseloads due to providing continuous eligibility under the bill’s provisions (General Fund and federal funds).
• Unknown, ongoing costs, likely hundreds of thousands, for the Department of Health Care Services (DHCS) for state administration (General Fund and federal funds).
• Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

Background:

The IHSS program provides in-home assistance to eligible low-income individuals who are disabled, blind, or at least 65 years of age or older to enable recipients to remain safely in their own homes. Personal care services include feeding, bathing, bowel and bladder care, meal preparation and clean up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings.

In order to be eligible for IHSS services, an individual must have a Medi-Cal eligibility determination. Counties are required to redetermine a Medi-Cal recipient’s eligibility whenever they receive information that indicates that their eligibility may have changed, such as a reported change in income or household size, as well as every 12 months from the date that a recipient’s eligibility was last determined. Medi-Cal recipients are also required to report any change in circumstances that may affect their eligibility within ten calendar days following the date the change occurred. 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.

Medi-Cal provides 12-month continuous eligibility for children, which means that even after a family’s income increases beyond the Medi-Cal limit, the child can keep Medi-Cal benefits for an additional year. California is currently in the process of applying for a federal waiver that would give children a continuous eligibility period from birth until their fifth birthday.

Proposed Law:

Specific provisions of the bill would:

• Require a recipient of IHSS to be continuously eligible for Medi-Cal for three years if they have a fixed income.
• Prohibit a redetermination of Medi-Cal eligibility from being conducted before three years unless DHCS or a county possesses facts indicating that the recipient has new income, has requested voluntary disenrollment, is deceased, is no longer a state resident, or their original enrollment was based on a state or county error or a recipient’s fraud, abuse, or perjury.
• Provide that a Medi-Cal recipient may still request a Medi-Cal redetermination prior to the end of the three-year continuous eligibility period.
• Condition implementation on all of the following:
  • All necessary federal approvals have been obtained.
  • The Legislature has appropriated funding to implement this section after a determination that ongoing General Fund resources are available to support the ongoing implementation of this section.
  • DHCS has determined that systems have been programmed to implement the provisions.
  • Any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.

-- END --

SENATE COMMITTEE ON GOVERNMENTAL ORGANIZATION

Senator Bill Dodd

Chair

2023 - 2024 Regular

Bill No: SB Hearing Date: 4/23/2024

SUBJECT:

DIGEST: This bill, to the extent that any necessary federal approvals are obtained and financial participation is available, requires that In-Home Supportive Services (IHSS) recipients be made continuously eligible for Medi-Cal for three years, and prohibits the redetermination of Medi-Cal eligibility before three years, except as specified, and exempts the State Department of Health Care Services (DHCS) from the Administrative Procedures Act (APA) by authorizing the department to implement this bill through all-county letters or similar instructions, as specified.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the State DHCS, under which qualified low-income individuals receive health care services, including IHSS.
2. Generally requires a county to re-determine a Medi-Cal beneficiary’s eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiary’s circumstances that may affect their eligibility for Medi-Cal benefits.
3. Provides for the IHSS program, administered by the State Department of Social Services (DSS) and counties, under which qualified aged, blind, and disabled persons are provided with supportive services in order to permit them to remain in their own homes and authorizes certain Medi-Cal beneficiaries to receive IHSS as a covered Medi-Cal benefit.
4. The APA governs the procedure for the adoption, amendment, or repeal of regulations by state agencies and for the review of those regulatory actions by the Office of Administrative Law (OAL).

This bill:

1. Requires that a recipient of IHSS be continuously eligible for Medi-Cal for three years, if they have a fixed income, as specified.
2. Prohibits the redetermination of Medi-Cal eligibility before three years, unless DHCS possesses facts indicating that the recipient has new income, the recipient has requested voluntary disenrollment, the recipient is deceased, the recipient is no longer a state resident, or the recipient’s original enrollment was based on a state or county error or on fraud, abuse, or perjury attributed to the recipient.
3. Specifies that the date of redetermination shall be three years from the most recent Medi-Cal determination.
4. Authorizes a Medi-Cal recipient to still request a Medi-Cal redetermination prior to the end of the three-year continuous eligibility period.
5. Specifies that implementation of this bill’s provisions is contingent on all of the following conditions:
   1. All necessary federal approvals have been obtained by DHCS, as specified.
   2. The Legislature has appropriated funding to implement this bill after a determination that ongoing General Fund resources are available to support the ongoing implementation of the bill.
   3. DHCS has determined that systems have been programmed to implement this bill.
6. Requires DHCS to issue a declaration certifying the date that all conditions above have been met and to post the declaration on its internet website and provide a copy of the declaration to the Secretary of State (SOS), the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.
7. Provides that this bill shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
8. Authorizes CDHS, notwithstanding the APA, to implement, interpret, or make specific this bill, in whole or in part, through all-county letters or similar instructions, without taking any further regulatory action, until such time that CDHS can promulgate regulations.
9. Provides that if the Commission on State Mandates determines that this act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made as specified.

Background

Author Statement. According to the author’s office, “every year, the most vulnerable of an already vulnerable population lose Medi-Cal and IHSS benefits because they did not submit their information in time; or lack knowledge, access, and assistance with an intimidating and cumbersome technological process. Most Long-Term Care and Aging experts agree that any changes in income for Medi-Cal beneficiaries who receive IHSS services are too insignificant to warrant yearly applications. SB 1355 would reduce the stress that aged, blind, and disabled beneficiaries of IHSS endure when completing forms, and save a lot administrative costs by not having to process forms that—for the most part—have no changes to report.”

Further, “SB 1355 calls for the Medi-Cal renewal process for IHSS recipients to be extended to every three years—unless there is a change in a recipient’s status (examples: death, change in income, no longer a state resident, among others)—with a federal waiver. Extending the eligibility period will ensure that the population who rely most on it will see fewer interruptions of their benefits.”

In-Home Supportive Services. The IHHS program provides in-home assistance to eligible low-income individuals who are disabled, blind, or at least 65 years of age or older to enable recipients to remain safely in their own homes. Currently, over 600,000 individuals are enrolled in the program. Personal care services include feeding, bathing, bowel and bladder care, meal preparation and clean up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings. In order to be eligible for IHSS services, an individual must be a California resident, have a Medi-Cal eligibility determination, live at home rather than a facility, and submit a completed Health Care Certification form. Once an application for services is approved and the level of needs is assessed, the individual must hire a provider to provide the authorized services.

Medi-Cal Eligibility Redetermination Requirements. Counties are required to re-determine a Medi-Cal recipient’s eligibility whenever they receive information that indicates that their eligibility may have changed, such as a reported change in income or household size, as well as every 12 months from the date that a recipient’s eligibility was last determined. Medi-Cal recipients are also required to report any change in circumstances that may affect their eligibility within ten calendar days following the date the change occurred. 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.

Federal law gives states the option to allow a 12-month continuous eligibility for children in Medicaid. California adopted this option in 2001, which means that even after a family’s income increases beyond the Medi-Cal limit, the child can keep Medi-Cal benefits for an additional year. This allows a child to be continuously covered even while a family’s income fluctuates, as is often the case for low-wage working families.

“Churn” of Eligible Medi-Cal Beneficiaries. “Churn” is the term used for the phenomena of Medicaid recipients losing coverage and subsequently reenrolling or reinstating within a short period of time. Although some recipients may experience temporary income fluctuations that make them ineligible for a short period of time, churn may also be an indicator of administrative barriers that disrupt coverage for recipients who continue to meet income and other eligibility requirements.

An October 2021 Medicaid and CHIP Payment and Access Commission (MACPAC) issue brief analyzed rates of churn and continuous coverage for Medicaid recipients in 2018 using enrollment data. MACPAC found that overall, about eight percent of full-benefit Medicaid recipients dis-enrolled and reenrolled within a year, though rates varied considerably across different states. On average, recipients in states with 12-month continuous eligibility and states that do not conduct midyear data checks for changes in circumstances were more likely to be enrolled in coverage for at least 12 months and were less likely to experience churn, as were those in states that made greater use of automated renewal processes.

As California is currently re-determining all Medi-Cal recipients following years of continuous eligibility for everyone during the COVID public health emergency, 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). A recent report by the California Health Care Foundation reviewing recent Medi-Cal terminations found that Californians 65 and older and those who qualify for Medi-Cal based on a disability are being dis-enrolled at a disproportionately high rate, as well as Spanish-speaking and Latino recipients.

Section 1115 Waiver Authority. Section 1115 of the Social Security Act allows states to apply to the U.S. Secretary of Health and Human Services to have certain federal Medicaid requirements waived, including the requirement to renew eligibility every 12 months. Waiver requests must be likely to assist in promoting the objectives of the program. To meet budget neutrality requirements of a Section 1115 demonstration, states identify savings—such as those from implementation of managed care or changes in benefits and cost sharing—in their proposed Section 1115 demonstrations that will offset the cost of any program expansion.

Section 1115 demonstrations include a research or evaluation component and usually are approved for a five-year period, with a possible three-year renewal period after the first five years. The Centers of Medicare & Medicaid Services (CMS) has approved ten-year demonstration extensions in a small number of cases. Although the specifics of each initiative vary, states have used Medicaid funds under Section 1115 authority to purchase premiums for exchange coverage, achieve savings through enrollment and eligibility restrictions or premium and cost sharing increases, expand the use of managed care, and restructure service delivery and payment systems.

Several states have used Section 1115 waivers to provide continuous eligibility for specific Medicaid populations. California is currently in the process of applying for a Section 1115 waiver that would give children a continuous eligibility period from birth until their fifth birthday, as required by SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), the 2022 health trailer bill. Whether the program will start is dependent on CMS’s approval of the waiver, as well as an appropriation from the Legislature this year.

While several states have similar requests or waivers for children, according to the Kaiser Family Foundation’s Medicaid Waiver Tracker, New Jersey and New York have approved waivers for 12-month continuous eligibility periods for adults whose eligibility is determined using the Modified Adjusted Gross Income methodology (most adults under age 65 or who are not disabled). Massachusetts has a pending waiver request for 12 months of continuous eligibility for all adults, 24 months of continuous eligibility for adults over age 65 experiencing homelessness, and is currently approved to provide 24 months of continuous eligibility for adults under age 65 experiencing homelessness and 12 months of continuous eligibility for adults leaving correctional settings. Pennsylvania also has a pending waiver for 12 months of continuous eligibility for adults leaving correctional settings. Finally, Kansas has an approved 12-month eligibility period for parents and caretaker relatives.

This bill would be an even more limited waiver request as it limits the population to just those receiving IHSS services, with a fixed income, and for whom the county has not received information that the recipient has new income. Typically, continuous eligibility periods continue regardless of any changes in a recipient’s income. Therefore, while this bill has a longer continuous eligibility period than others for adults, the likelihood that the affected individuals are actually currently eligible for the program are much higher.

The California Administrative Procedures Act. The APA, originally established by SB 705 (DeLap, Chapter 867, Statutes of 1945), predates the federal version and is a set of laws and regulations that governs how state agencies in California must conduct administrative rulemaking and adjudicative proceedings. The APA was established in response to concerns that the number of administrative regulations had grown significantly, and that many regulations were written in an unclear and unnecessarily complex manner. The APA aims to ensure that regulations are written in a comprehensible manner, are authorized by statute, and are consistent with other law.

To achieve these goals, the APA established the OAL as a central office within state government charged with the orderly review of adopted regulations. The OAL is responsible for reviewing regulations to ensure that they are written in a comprehensible manner, are authorized by statute, and are consistent with other law. The OAL is also tasked with reducing the number of administrative regulations and improving the quality of those regulations that are adopted.

State agencies must actively seek to reduce the unnecessary regulatory burden on private individuals and entities by substituting performance standards for prescriptive standards wherever performance standards can be reasonably expected to be as effective and less burdensome, and that this substitution shall be considered during the course of the agency rulemaking process.

The APA requires that state agencies must give the OAL ready access to their records and full information and reasonable assistance in any matter of research requiring recourse to them or to data within their knowledge or control.

Furthermore, any interested person may petition a state agency requesting the adoption, amendment, or repeal of a regulation as provided in Article 5 of the APA. The state agency must notify the petitioner in writing of the receipt and must within 30 days deny the petition indicating why the agency has reached its decision on the merits of the petition in writing or schedule the matter for public hearing in accordance with the notice and hearing requirements of that article.

The APA was designed to promote transparency, fairness, and public participation in the administrative process. Its main objectives are to ensure that regulations are written in a comprehensible manner, are authorized by statute, and are consistent with other law. The APA established the OAL to review and improve the quality of adopted regulations, and state agencies must actively seek to reduce the unnecessary regulatory burden on private individuals and entities.

When considering exemptions to the APA, it is important to consider what else that may lead to such as reduced transparency and accountability, risk of arbitrary decisions, and potential legal challenges. Limiting the public’s opportunity for input and oversight may result in a higher risk of arbitrary or inconsistent decision-making in the development and implementation of the program’s guidelines.

All County Letters. DSS regularly publishes formal communications known as all county letters (ACLs) and All County Information Notices (ACINs) that have information on legislative changes, regulations, policy, programs, and benefits. These letters are one of the primary means through which the state communicates important information related to the administration of social services, including but not limited to, public assistance, child welfare, and adult services. DSS maintains an archive of all ACLs issued by year, dating back to 1974, on the department’s internet website.

This bill exempts CDPH from specified APA requirements by authorizing the department to implement, interpret, or make specific this bill, in whole or in part, through ACLs or similar instructions, without taking any further regulatory action.

Prior/Related Legislation

SB 1104 (Niello, 2024) establishes the Office of Regulatory Counsel to draft and assist in the preparation, consideration, amendment, and repeal of regulations for a state agency, before the state agency submits a proposed action regarding that regulation to OAL for publication in the California Regulatory Notice Register, as specified. (Pending in the Senate Appropriations Committee)

SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022) the 2022 Budget health trailer bill, among other things, deleted certain requirements related to re-determining eligibility of Medi-Cal beneficiaries to align with federal guidelines, including the requirement on counties to prepopulate the form, and the requirement on beneficiaries to sign or return the form.

SB 705 (DeLap, Chapter 867, Statutes of 1945) established the APA, which governs the procedure for the adoption, amendment, or repeal of regulations by state agencies and for the review of those regulatory actions by the OAL.

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

SUPPORT:

Coalition of California Welfare Rights Organizations (Source)

California In-Home Supportive Services Consumer Alliance

Educate Advocate

OPPOSITION:

None received

ARGUMENTS IN SUPPORT: In support of the bill, the Coalition of California Welfare Rights Organizations writes that, “SB 1355 calls for the Medi-Cal renewal process for IHSS recipients to be extended to every three years, unless there is a change in a recipient’s status (examples: death, change in income, no longer a state resident, among others) with a federal waiver. Extending the eligibility period will ensure that the population who rely most on it will see fewer interruptions of their benefits.”

Further, “Medi-Cal annual redeterminations often lead to loss of Medi-Cal benefits, and thus also IHSS services, because the beneficiaries are not able to effectively navigate California’s 58 different county business practices for re-determining Medi-Cal eligibility annually. This leads to closure of Medi-Cal and IHSS cases and services due to ‘procedural’ reasons – they are income and resource eligible otherwise. We have helped many IHSS beneficiaries who have lost their Medi-Cal and lost IHSS services due to these bureaucratic county business practice barriers.”

DUAL REFERRAL: Senate Health Committee (10-0) & Senate Governmental Organization Committee

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: SB 1355

SUBJECT: Medi-Cal: in-home supportive services: redetermination

SUMMARY:

Prohibits subjecting a Medi-Cal recipient on a fixed income who is receiving In-Home Supportive Services to Medi-Cal eligibility redetermination before three years, except in specified circumstances.

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC § 14000 et seq.]
2. 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. [WIC §14005.37]
3. Requires DHCS to exercise the option under federal Medicaid law to extend continuous eligibility to children under 19 years of age, which requires a child to remain Medi-Cal eligible from the date of a determination of eligibility for Medi-Cal benefits until the earlier of either the end of a 12-month period following the eligibility determination or the date the individual turns 19 years old. [WIC §14005.25]
4. Prohibits the redetermination of Medi-Cal eligibility for a child under five years of age, unless DHCS or the county possesses facts indicating that the family has requested the child's voluntary disenrollment, the child is deceased, the child is no longer a state resident, or the child's original enrollment was based on a state or county error or on fraud, abuse, or perjury attributed to the child or the child's representative. [WIC § 14005.255]
5. Establishes the In-Home Supportive Services (IHSS) program, administered by the California Department of Social Services (CDSS) to provide supportive services to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. [WIC § 12300 et seq.]
6. Specifies that supportive services include domestic and related services, heavy cleaning, personal care services, accompaniment by a provider during necessary travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, teaching and demonstration directed at reducing the need for other supportive services, and paramedical services which make it possible for the recipient to establish and maintain an independent living arrangement. [WIC § 12300]
7. Requires a county welfare department to assess each IHSS recipient’s continuing monthly need for IHSS at varying intervals as necessary, but at least once every 12 months. Allows counties to extend assessments on a case-by-case basis for up to six months beyond the regular 12-month period for recipients if a number of specific conditions exist that demonstrate that the IHSS needs would not change. [WIC § 12301.1]
   

This bill:

1. Requires a recipient of IHSS to be continuously eligible for Medi-Cal for three years if they have a fixed income.
2. Prohibits a redetermination of Medi-Cal eligibility from being conducted before three years unless DHCS or a county possesses facts indicating that the recipient has new income, has requested voluntary disenrollment, is deceased, is no longer a state resident, or their original enrollment was based on a state or county error or a recipient’s fraud, abuse, or perjury.
3. Conditions the implementation of this bill upon the receipt of federal approvals, an appropriation by the Legislature after a determination that ongoing General Fund resources are available to support the ongoing implementation of this bill, DHCS has determined that systems have been programmed to implement this section, and federal funding is not otherwise jeopardized.
4. Permits DHCS to implement the bill without taking any further regulatory action.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, every year, the most vulnerable of an already vulnerable population lose Medi-Cal and IHSS benefits because they did not submit their information in time; or, lack knowledge, access, and assistance with an intimidating and cumbersome technological process. Most Long-Term Care and Aging experts agree that as a group, any changes in income for Medi-Cal recipients who receive IHSS services are too insignificant to warrant yearly applications. This bill would reduce the stress that aged, blind and disabled beneficiaries of IHSS endure when completing forms and save a lot of administrative costs by not having to process forms that for the most part, have no changes to report. This bill calls for the Medi-Cal renewal process for IHSS recipients to be extended to every three years, unless there is a change in a recipient’s status (examples: death, change in income, no longer a state resident, among others) with a federal waiver. Extending the eligibility period will ensure that the population who rely most on it will see fewer interruptions of their benefits.
2. IHSS. The IHHS program provides in-home assistance to eligible low-income individuals who are disabled, blind, or at least 65 years of age or older to enable recipients to remain safely in their own homes. Currently, over 600,000 individuals are enrolled in the program. Personal care services include feeding, bathing, bowel and bladder care, meal preparation and clean up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings. In order to be eligible for IHSS services, an individual must be a California resident, have a Medi-Cal eligibility determination, live at home rather than a facility, and submit a completed Health Care Certification form. Once an application for services is approved and the level of needs is assessed, the individual must hire a provider to provide the authorized services.
3. Medi-Cal eligibility redetermination requirements. Counties are required to redetermine a Medi-Cal recipient’s eligibility whenever they receive information that indicates that their eligibility may have changed, such as a reported change in income or household size, as well as every 12 months from the date that a recipient’s eligibility was last determined. Medi-Cal recipients are also required to report any change in circumstances that may affect their eligibility within ten calendar days following the date the change occurred. 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.

Federal law gives states the option to allow a 12-month continuous eligibility for children in Medicaid. California adopted this option in 2001, which means that even after a family’s income increases beyond the Medi-Cal limit, the child can keep Medi-Cal benefits for an additional year. This allows a child to be continuously covered even while a family’s income fluctuates, as is often the case for low-wage working families.

1. “Churn” of eligible Medi-Cal beneficiaries. “Churn” is the term used for the phenomena of Medicaid recipients losing coverage and subsequently reenrolling or reinstating within a short period of time. Although some recipients may experience temporary income fluctuations that make them ineligible for a short period of time, churn may also be an indicator of administrative barriers that disrupt coverage for recipients who continue to meet income and other eligibility requirements. An October 2021 Medicaid and CHIP Payment and Access Commission (MACPAC) issue brief analyzed rates of churn and continuous coverage for Medicaid recipients in 2018 using enrollment data. MACPAC found that overall, about 8% of full-benefit Medicaid recipients disenrolled and reenrolled within a year, though rates varied considerably across different states. On average, recipients in states with 12-month continuous eligibility and states that do not conduct midyear data checks for changes in circumstances were more likely to be enrolled in coverage for at least 12 months and were less likely to experience churn, as were those in states that made greater use of automated renewal processes. California fits into these categories.

As California is currently redetermining all Medi-Cal recipients following years of continuous eligibility for everyone during the COVID public health emergency, 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). A recent report by the California Health Care Foundation reviewing recent Medi-Cal terminations found that Californians 65 and older and those who qualify for Medi-Cal based on a disability are being disenrolled at a disproportionately high rate, as well as Spanish-speaking and Latino recipients.

1. Section 1115 waiver authority. Section 1115 of the Social Security Act allows states to apply to the U.S. Secretary of Health and Human Services to have certain federal Medicaid requirements waived, including the requirement to renew eligibility every 12 months. Waiver requests must be likely to assist in promoting the objectives of the program. To meet budget neutrality requirements of a Section 1115 demonstration, states identify savings—such as those from implementation of managed care or changes in benefits and cost sharing—in their proposed Section 1115 demonstrations that will offset the cost of any program expansion. Section 1115 demonstrations include a research or evaluation component and usually are approved for a five-year period, with a possible three-year renewal period after the first five years. CMS has approved ten-year demonstration extensions in a small number of cases. Although the specifics of each initiative vary, states have used Medicaid funds under Section 1115 authority to purchase premiums for exchange coverage, achieve savings through enrollment and eligibility restrictions or premium and cost sharing increases, expand the use of managed care, and restructure service delivery and payment systems.

Several states have used Section 1115 waivers to provide continuous eligibility for specific Medicaid populations. California is currently in the process of applying for a Section 1115 waiver that would give children a continuous eligibility period from birth until their fifth birthday, as required by SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), the 2022 health trailer bill. Whether the program will start is dependent on CMS’s approval of the waiver, as well as an appropriation from the Legislature this year. While several states have similar requests or waivers for children, according to the Kaiser Family Foundation’s Medicaid Waiver Tracker, New Jersey and New York have approved waivers for 12-month continuous eligibility periods for adults whose eligibility is determined using the Modified Adjusted Gross Income methodology (most adults under age 65 or who are not disabled). Massachusetts has a pending waiver request for 12 months of continuous eligibility for all adults, 24 months of continuous eligibility for adults over age 65 experiencing homelessness, and is currently approved to provide 24 months of continuous eligibility for adults under age 65 experiencing homelessness and 12 months of continuous eligibility for adults leaving correctional settings. Pennsylvania also has a pending waiver for 12 months of continuous eligibility for adults leaving correctional settings. Finally, Kansas has an approved 12-month eligibility period for parents and caretaker relatives.

This bill would be an even more limited waiver request as it limits the population to just those receiving IHSS services, with a fixed income, and for whom the county has not received information that the recipient has new income. Typically, continuous eligibility periods continue regardless of any changes in a recipient’s income. Therefore, while this bill has a longer continuous eligibility period than others for adults, the likelihood that the affected individuals are actually currently eligible for the program are much higher.

1. Double referral. This bill is double referred. Should it pass out of this Committee, it will be referred to the Senate Committee on Governmental Organization.
2. Related legislation. AB 2956 (Boerner) makes various changes to the Medi-Cal redetermination process including requiring DHCS to seek federal approval to extend the 12-month continuous eligibility period currently available to children to adults. AB 2956 is set for hearing on April 16, 2024 in the Assembly Health Committee.
3. Prior legislation. SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022) created a continuous eligibility period for children in Medi-Cal, the Medi-Cal Access Program, and the County Children’s Health Initiative Programs until age five, without the need for redetermination except in specified circumstances, subject to an appropriation by the Legislature.

AB 2402 (Rubio of 2022) was substantially similar to SB 184. The contents of AB 2402 were included in SB 184.

AB 2900 (Gallegos, Chapter 945, Statutes of 2000) required DHCS to exercise the option under federal Medicaid law to extend a 12-month continuous eligibility period to children 19 years of age and younger.

1. Support. Sponsor Coalition of California Welfare Rights Organizations writes that Medi-Cal annual redeterminations often lead to loss of Medi-Cal benefits, and thus IHSS services also, because recipients are not able to effectively navigate California’s 58 different county business practices for redetermining Medi-Cal eligibility annually. This leads to closure of Medi-Cal and IHSS cases and services due to “procedural” reasons – they are income and resource eligible otherwise. They state they have helped many IHSS recipients who have lost their Medi-Cal and lost IHSS services due to these bureaucratic county business practice barriers. This bill would reduce the stress that aged, blind and disabled beneficiaries of IHSS endure by completing forms when for most part they have nothing new to report except that they are getting older. It would also save administrative costs by not processing forms that have nothing to report or restoring cases for failure to get a form to the county that had nothing to report in the first place.
2. Amendments. The author and the committee have agreed to amendments that would do the following:
3. Clarify the start date of the continuous eligibility period;
4. Clarify that Medi-Cal beneficiaries may still request a redetermination; and,
5. Require DHCS to eventually promulgate regulations.

SUPPORT AND OPPOSITION:

Support: Coalition of California Welfare Rights Organizations (sponsor)

California In-Home Supportive Services Consumer Alliance

Oppose: None received

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