BILL NUMBER: AB 1 AMENDED
BILL TEXT
AMENDED IN SENATE SEPTEMBER 7, 2007
AMENDED IN SENATE SEPTEMBER 4, 2007
AMENDED IN SENATE JULY 2, 2007
AMENDED IN ASSEMBLY JUNE 1, 2007
AMENDED IN ASSEMBLY MAY 1, 2007
AMENDED IN ASSEMBLY APRIL 19, 2007
AMENDED IN ASSEMBLY MARCH 29, 2007
INTRODUCED BY Assembly Members Laird and Dymally
(Principal coauthor: Senator Steinberg)
(Coauthors: Assembly Members Berg , Hancock, and Wolk)
DECEMBER 4, 2006
An act to amend Section 123870 of the Health and Safety Code, to
amend Sections 12693.43, 12693.70, 12693.73, 12693.76, 12693.98,
12693.98a, and 12694 of, to amend and repeal Section
12693.981 of, to add Sections 12693.55
12693.55.1 , 12693.56, 12693.57, 12693.701, 12693.981a,
and 12693.983 to, and to add Chapter 16.2 (commencing with Section
12694.1) to Part 6.2 of Division 2 of, the Insurance Code, and to
amend Sections 14005.23, 14011.65, and 14011.65a of, and to add
Sections 14005.26, 14011.01, and 14011.61 to, the Welfare and
Institutions Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1, as amended, Laird. Health care coverage.
(1) Existing law establishes various public programs to provide
health care coverage to eligible children, including the Medi-Cal
program administered by the State Department of Health Care Services
and county welfare agencies, and the Healthy Families Program
administered by the Managed Risk Medical Insurance Board. Children
through 18 years of age are eligible for health care coverage under
these programs if they meet certain household income and other
criteria, including specified citizenship and immigration status
requirements. Under existing law, the applicant's signed statement as
to the value or amount of income is accepted for eligibility
purposes under the Healthy Families Program if documentation cannot
otherwise be provided. Existing law requires the Managed Risk Medical
Insurance Board and the Department of Insurance, in collaboration
with entities administering the California Special Supplemental Food
Program for Women, Infants, and Children (WIC), to develop an
automated enrollment gateway system allowing a presumptive
eligibility determination for the Medi-Cal program and the Healthy
Families Program to be made for children applying for the WIC
program.
This bill would expand eligibility for the Medi-Cal program and
would expand eligibility for the Healthy Families Program by allowing
children with family incomes at or below 300% of the federal poverty
level to qualify for the program and would delete the specified
citizenship and immigration status requirements. The bill would
require the Managed Risk Medical Insurance Board, by January 2008, in
consultation with stakeholders, to implement a process for an
applicant's self-certification of income and income deductions for
purposes of establishing eligibility for the Healthy Families
Program. The bill would create the Healthy Families Buy-In Program
that would be administered by the Managed Risk Medical Insurance
Board and would make the coverage provided under the Healthy Families
Program available to children whose household income exceeds 300% of
the federal poverty level and who meet other specified criteria. The
bill would specify that coverage under the buy-in program would
include services provided under the California Children's Services
Program (CCSP) for children eligible for CCSP and would deem the
child's family financially eligible for benefits under CCSP. Because
the bill would thereby expand eligibility for the CCSP, which is
administered by a county's public health or social welfare
department, it would impose a state-mandated local program. The bill
would specify the family contribution required for children enrolled
in the buy-in program and would require an additional payment, as
determined by the Managed Risk Medical Insurance Board, from the
family of a child determined eligible for CCSP. The bill would also
make various related modifications to the Medi-Cal program and the
Healthy Families Program, and would require the State Department of
Health Care Services and the Managed Risk Medical Insurance Board to
maximize federal matching funds for the Medi-Cal program and the
Healthy Families Program. Because the expansion of and modifications
to the Medi-Cal program would impose certain duties on counties
relative to administration of that program, the bill would impose a
state-mandated local program. The bill would require the Managed Risk
Medical Insurance Board and the State Department of Health Care
Services to take specified actions to improve and coordinate the
application and enrollment processes for the Medi-Cal program and the
Healthy Families Program and to develop a process to transition the
enrollment of children from local children's health initiatives into
those programs. The bill would specify that an entity's use of the
automated enrollment gateway system for presumptive eligibility
determinations for WIC applicants would be required only to the
extent that adequate financial assistance is available for that
purpose.
(2) Existing law establishes the Healthy Families-to-Medi-Cal
Bridge Benefits Program to provide any person enrolled for coverage
under the Healthy Families Program who meets certain criteria, as
specified, with 2 calendar months of health care benefits in order to
provide the person with the opportunity to apply for the Medi-Cal
program.
This bill would establish the Healthy Families to Medi-Cal
Presumptive Eligibility Program to provide a child who meets certain
criteria, as specified, with presumptive eligibility benefits
identical to the full scope of benefits provided under the Medi-Cal
program until a Medi-Cal eligibility determination is made, at which
point either the child would be enrolled in the Medi-Cal program with
no interruption in coverage or the presumptive eligibility benefits
would terminate in accordance with due process requirements. The bill
would require the Managed Risk Medical Insurance Board to execute a
declaration upon implementation of this program and would
make the Healthy Families-to-Medi-Cal Bridge Benefits Program
inoperative as of the date of that declaration .
(3) Existing law establishes the Healthy Families Presumptive
Eligibility Program, administered by the Managed Risk Medical
Insurance Board, to provide a child who satisfies specified criteria
with health care benefits while the board determines the child's
eligibility for the Healthy Families Program.
This bill would rename the program the Medi-Cal to Healthy
Families Presumptive Eligibility Program and would require the
Managed Risk Medical Insurance Board and the State Department of
Health Care Services to monitor the program to ensure children are
timely enrolled in the presumptive eligibility benefits for which
they are eligible.
(4) Existing law requires the state to administer, to the extent
allowed under federal law, and only if federal financial
participation is available, the Medi-Cal to Healthy Families
Presumptive Eligibility Program to provide a child who meets
specified eligibility requirements, including the income requirements
of the Healthy Families Program, with benefits identical to full
scope benefits under the Medi-Cal program with no share of cost for
the period during which the child has an application pending for
coverage under the Healthy Families Program. Under existing law, this
program becomes inoperative 3 years after its implementation.
This bill would rename the program the Healthy Families
Presumptive Eligibility Program and would delete the provisions
making the program inoperative. The bill would also establish, to the
extent allowed by federal law and to the extent federal financial
participation is available, the Medi-Cal Presumptive Eligibility
Program that would provide a child who meets specified eligibility
requirements with presumptive eligibility benefits identical to full
scope benefits under the Medi-Cal program with no share of cost until
the child is found eligible for the Medi-Cal program. The bill would
require the county to forward the child's application to the Healthy
Families Program if it finds the child eligible for the Medi-Cal
program with a share of cost.
(5) Existing law creates the Healthy Families Fund, and provides
that money in the fund is continuously appropriated for purposes of
the Healthy Families Program.
This bill would provide that the Managed Risk Medical Insurance
Board may implement the provisions of the bill expanding the Healthy
Families Program only to the extent that funds are appropriated for
those purposes in the annual Budget Act or in another statute.
(6) This bill would incorporate additional changes to Section
123870 of the Health and Safety Code proposed by SB 137, to be
operative only under circumstances specified in the bill.
(6)
(7) The California Constitution requires the state to
reimburse local agencies and school districts for certain costs
mandated by the state. Statutory provisions establish procedures for
making that reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. It is the intent of the Legislature to accomplish the
following:
(a) Allow all children, from birth to 19 years of age, living in
California to have access to affordable, comprehensive health care
coverage.
(b) Build upon the successful aspects of California's publicly
funded state health care coverage programs, the Healthy Families
Program and the Medi-Cal program, and improve their operations,
including modernizing and simplifying the processes of enrolling all
eligible children in coverage and maintaining their enrollment in the
programs.
(c) Build upon the lessons and successes of local children's
health initiatives.
(d) Support coverage for children currently enrolled in local
children's health initiatives until the expansion of the statewide
program is fully implemented and provide for a smooth transition for
these children into the Healthy Families Program and the Medi-Cal
program.
(e) Ensure sustainable financing that supports the statewide
programs over the long term, including maximizing federal funding for
those programs.
SEC. 2. Section 123870 of the Health and Safety Code is amended to
read:
123870. (a) The department shall establish standards of financial
eligibility for treatment services under the California Children's
Services Program (CCS program).
(1) Financial eligibility for treatment services under this
program shall be limited to persons in families with an adjusted
gross income of forty thousand dollars ($40,000) or less in the most
recent tax year, as calculated for California state income tax
purposes. If a person is enrolled in the Healthy Families Program
(Part 6.2 (commencing with Section 12693) of Division 2 of the
Insurance Code), the financial documentation required for that
program in Section 2699.6600 of Title 10 of the California Code of
Regulations may be used instead of the person's California state
income tax return. However, the director may authorize treatment
services for persons in families with higher incomes if the estimated
cost of care to the family in one year is expected to exceed 20
percent of the family's adjusted gross income.
(2) Children enrolled in either the Healthy Families Program or
the Healthy Families Buy-In Program who have a CCS program eligible
medical condition under Section 123830, and whose families do not
meet the financial eligibility requirements of paragraph (1), shall
be deemed financially eligible for CCS program benefits.
(b) Necessary medical therapy treatment services under the
California Children's Services Program rendered in the public schools
shall be exempt from financial eligibility standards and enrollment
fee requirements for the services when rendered to any handicapped
child whose educational or physical development would be impeded
without the services.
(c) All counties shall use the uniform standards for financial
eligibility and enrollment fees established by the department. All
enrollment fees shall be used in support of the California Children's
Services Program.
(d) Annually, every family with a child eligible to receive
services under this article shall pay a fee of twenty dollars ($20),
that shall be in addition to any other program fees for which the
family is liable. This assessment shall not apply to any child who is
eligible for full scope Medi-Cal benefits without a share of cost,
for children receiving therapy through the California Children's
Services Program as a related service in their individualized
education plans, for children from families having incomes of less
than 100 percent of the federal poverty level, or for children
covered under the Healthy Families Program or the Healthy Families
Buy-In Program.
SEC. 2.5. Section 123870 of the Health
and Safety Code is amended to read:
123870. (a) The department shall establish standards of financial
eligibility for treatment services under the California Children's
Services Program (CCS program).
(1) (A) Financial eligibility for treatment
services under this program shall be limited to persons in
families with an adjusted gross income of a family
with an annual income, or the equivalent monthly income, equal to or
less than forty thousand dollars ($40,000) or less in
the most recent tax year, as calculated for California state income
tax purposes. If a person is enrolled in , or that
meets the income eligibility requirements for the Healthy
Families Program (Part 6.2 (commencing with Section 12693) of
Division 2 of the Insurance Code) , as set forth in paragraph
(6) of subdivision (a) of Section 12693.70 of the Insurance Code.
However, the director may authorize treatment services for persons in
families with higher incomes if the estimated cost of care to the
family in one year is expected to exceed 20 percent of the family's
adjusted gross income. When calculating annual or monthly income
under this paragraph, any income deduction that is applicable to a
child under the Medi-Cal program shall be applied in
determining the annual or monthly household income for eligibility
under the CCS program.
(B) If a person is enrolled in the
Healthy Families Program , the financial documentation required
for that program in Section 2699.6600 of Title 10 of the California
Code of Regulations may be used instead of the person's California
state income tax return. However, the director may authorize
treatment services for persons in families with higher incomes if the
estimated cost of care to the family in one year is expected to
exceed 20 percent of the family's adjusted gross income.
(2) Children enrolled in either the Healthy Families
Program or the Healthy Families Buy-In Program who have a
CCS program eligible medical condition under Section 123830, and
whose families do not meet the financial eligibility requirements of
paragraph (1), shall be deemed financially eligible for CCS program
benefits.
(b) Necessary medical therapy treatment services under the
California Children's Services Program rendered in the public schools
shall be exempt from financial eligibility standards and enrollment
fee requirements for the services when rendered to any handicapped
child whose educational or physical development would be impeded
without the services.
(c) All counties shall use the uniform standards for financial
eligibility and enrollment fees established by the department. All
enrollment fees shall be used in support of the California Children's
Services Program.
(d) Annually, every family with a child eligible to receive
services under this article shall pay a fee of twenty dollars ($20),
that shall be in addition to any other program fees for which the
family is liable. This assessment shall not apply to any child who is
eligible for full scope Medi-Cal benefits without a share of cost,
for children receiving therapy through the California Children's
Services Program as a related service in their individualized
education plans, for children from families having incomes of less
than 100 percent of the federal poverty level, or for children
covered under the Healthy Families Program or the Healthy
Families Buy-In Program .
SEC. 3. Section 12693.43 of the Insurance Code is amended to read:
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost family value
package in a given geographic area.
(b) In each geographic area, the board shall designate one or more
family value packages for which the required total family
contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with an annual household income up to and including 150
percent of the federal poverty level.
(2) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with an annual household income greater than 150 percent
and up to and including 200 percent of the federal poverty level and
for applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (5) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with an annual household income to
which subparagraph (B) of paragraph (5) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (5) of subdivision (a) of Section 12693.70 is applicable,
then this paragraph shall be applicable to the applicant on July 1,
2005, unless subparagraph (B) of paragraph (5) of subdivision (a) of
Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this paragraph and, prior to the date the premium
increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (5) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(4) Twenty-two dollars and fifty cents ($22.50) per child with a
maximum required contribution of sixty-seven dollars and fifty cents
($67.50) per month per family for applicants on behalf of children
with an annual household income described in subparagraph (C) of
paragraph (5) of subdivision (a) of Section 12693.70.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost family value package
may be offered to and selected by applicants. However, the cost to
the program of those combinations that exceeds the price to the
program of the highest cost family value package shall be paid by the
applicant as part of the family contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with an annual household income up to and
including 150 percent of the federal poverty level.
(2) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (5) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, twelve dollars ($12) per child with
a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with an annual household income to
which subparagraph (B) of paragraph (5) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (5) of subdivision (a) of Section 12693.70 is applicable,
then this paragraph shall be applicable to the applicant on July 1,
2005, unless subparagraph (B) of paragraph (5) of subdivision (a) of
Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this paragraph and, prior to the date the premium
increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (5) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(4) Sixteen dollars ($16) per child with a maximum required
contribution of forty-eight dollars ($48) per month per family for
applicants on behalf of children with an annual household income
described in subparagraph (C) of paragraph (5) of subdivision (a) of
Section 12693.70.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purposes of
subdivision (e) of Section 11346.1 of the Government Code, the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative Law, is hereby extended to 180 days.
SEC. 4. Section 12693.55 12693.55.1
is added to the Insurance Code, to read:
12693.55. 12693.55.1. The board and
the State Department of Health Care Services shall maximize federal
matching funds available under the program and the Medi-Cal program
and shall implement strategies that coordinate and integrate other
programs that provide health care coverage for children to maximize
federal matching, such as matching funds available for emergency or
pregnancy-related benefits under the Medi-Cal program for all
eligible children.
SEC. 5. Section 12693.56 is added to the Insurance Code, to read:
12693.56. The confidentiality and privacy protections of Sections
10500 and 14100.2 of the Welfare and Institutions Code shall apply
to all children seeking, applying for, or enrolled in, the program.
SEC. 6. Section 12693.57 is added to the Insurance Code, to read:
12693.57. Upon implementation of Section 14005.26 of the Welfare
and Institutions Code and Section 12693.701, the board, in
consultation with the State Department of Health Care Services, shall
develop a process for the transition of eligible children from local
children's health initiatives to the Medi-Cal program and to the
Healthy Families Program. The process shall include, but not be
limited to, the following provisions:
(a) A child enrolled in comprehensive health care coverage
provided by a children's health initiative shall be automatically
enrolled in the Medi-Cal program or the Healthy Families Program,
pursuant to subdivisions (b) and (c), if an application is made and
the child is eligible for either program. The child shall be enrolled
in the same health plan that provided coverage to the child under
the local children's health initiative, if the health plan is a
participating plan in the Medi-Cal program or the Healthy Families
Program.
(b) The automatic enrollment process described in subdivision (a)
shall, for each local children's health initiative, only occur after
the board and the State Department of Health Care Services have
developed and implemented a plan with each local children's health
initiative to ensure all children are transferred to the Medi-Cal
program or the Healthy Families Program without a disruption in
coverage. The board and the State Department of Health Care Services
shall develop these plans with local children's health initiatives
and children's advocates. These plans shall include, but not be
limited to, all of the following:
(1) A timely process for communicating with families of eligible
children about their eligibility, coverage options, and the automatic
enrollment process.
(2) Development and implementation of an effective and secure
process for transferring information and any prepaid premiums from
local children's health initiatives to the board and department, as
well as gathering additional information needed to complete
appropriate applications.
(3) Training on this transfer of children and their coverage for
local eligibility workers, Certified Application Assistors, and other
local children's health initiative organizations assisting this
population.
(c) The automatic enrollment process described in subdivision (a)
shall only occur after the board has implemented the confidentiality
and privacy standards pursuant to Section 12693.56 and the board and
department have implemented the other functions necessary to operate
the eligibility expansion pursuant to Sections 12693.43, 12693.70,
12693.701, and 12693.76, and Sections 14005.23 and 14005.26 of the
Welfare and Institutions Code.
(d) The board and department shall complete the activities
described in subdivisions (b) and (c) no later than July 1, 2008.
(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the board
and department may issue regulations, all-county letters or similar
instructions, as necessary pursuant to the Administrative Procedure
Act, to implement the requirements of this section. The adoption and
readoption of regulations pursuant to this section shall be deemed to
be an emergency and necessary for the immediate preservation of
public peace, health and safety, or general welfare.
(f) Upon a child's enrollment in the Medi-Cal program or in the
Healthy Families Program, the department or the board shall
immediately notify the child's family that it may change coverage to
another health plan. The family may make this change at any time
within 90 days from the date of its receipt of this notice.
SEC. 7. Section 12693.70 of the Insurance Code is amended to
read:
12693.70. To be eligible to participate in the program, an
applicant shall meet all of the following requirements:
(a) Be an applicant applying on behalf of an eligible child, which
means a child who is all of the following:
(1) Less than 19 years of age. An application may be made on
behalf of a child not yet born up to three months prior to the
expected date of delivery. Coverage shall begin as soon as
administratively feasible, as determined by the board, after the
board receives notification of the birth. However, no child less than
12 months of age shall be eligible for coverage until 90 days after
the enactment of the Budget Act of 1999.
(2) Not eligible for no-cost full-scope Medi-Cal or Medicare
coverage at the time of application.
(3) In compliance with Sections 12693.71 and 12693.72.
(4) A resident of the State of California pursuant to Section 244
of the Government Code; or, if not a resident pursuant to Section 244
of the Government Code, is physically present in California and
entered the state with a job commitment or to seek employment,
whether or not employed at the time of application to or after
acceptance in, the program.
(5) (A) In either of the following:
(i) In a family with an annual or monthly household income equal
to or less than 200 percent of the federal poverty level.
(ii) When implemented by the board, subject to subdivision (b) of
Section 12693.765 and pursuant to this section, a child under the age
of two years who was delivered by a mother enrolled in the Access
for Infants and Mothers Program as described in Part 6.3 (commencing
with Section 12695). Commencing July 1, 2007, eligibility under this
subparagraph shall not include infants during any time they are
enrolled in employer-sponsored health insurance or are subject to an
exclusion pursuant to Section 12693.71 or 12693.72, or are enrolled
in the full scope of benefits under the Medi-Cal program at no share
of cost. For purposes of this clause, any infant born to a woman
whose enrollment in the Access for Infants and Mothers Program begins
after June 30, 2004, shall be automatically enrolled in the Healthy
Families Program, except during any time on or after July 1, 2007,
that the infant is enrolled in employer-sponsored health insurance or
is subject to an exclusion pursuant to Section 12693.71 or 12693.72,
or is enrolled in the full scope of benefits under the Medi-Cal
program at no share of cost. Except as otherwise specified in this
section, this enrollment shall cover the first 12 months of the
infant's life. At the end of the 12 months, as a condition of
continued eligibility, the applicant shall provide income
information. The infant shall be disenrolled if the gross annual
household income exceeds the income eligibility standard that was in
effect in the Access for Infants and Mothers Program at the time the
infant's mother became eligible, or following the two-month period
established in Section 12693.981 or the period established in Section
12693.981a if the infant is eligible for Medi-Cal with no share of
cost. At the end of the second year, infants shall again be screened
for program eligibility pursuant to this section, with income
eligibility evaluated pursuant to clause (i), subparagraphs (B) and
(C), and paragraph (2) of subdivision (a).
(B) All income over 200 percent of the federal poverty level but
less than or equal to 250 percent of the federal poverty level shall
be disregarded in calculating annual or monthly household income.
(C) All income over 250 percent of the federal poverty level but
less than or equal to 300 percent of the federal poverty level shall
be disregarded in calculating annual or monthly household income.
(D) In a family with an annual or monthly household income greater
than 300 percent of the federal poverty level, any income deduction
that is applicable to a child under Medi-Cal shall be applied in
determining the annual or monthly household income. If the income
deductions reduce the annual or monthly household income to 300
percent or less of the federal poverty level, subparagraph (C) shall
be applied.
(b) The applicant shall agree to remain in the program for six
months, unless other coverage is obtained and proof of the coverage
is provided to the program.
(c) An applicant shall enroll all of the applicant's eligible
children in the program.
(d) In filing documentation to meet program eligibility
requirements, if the applicant's income documentation cannot be
provided, as defined in regulations promulgated by the board, the
applicant's signed statement as to the value or amount of income
shall be deemed to constitute verification.
(e) An applicant shall pay in full any family contributions owed
in arrears for any health, dental, or vision coverage provided by the
program within the prior 12 months.
(f) By January 2008, the board, in consultation with stakeholders,
shall implement processes by which applicants for subscribers may
certify income at the time of annual eligibility review, including
rules concerning which applicants shall be permitted to certify
income and the circumstances in which supplemental information or
documentation may be required. The board may terminate using these
processes not sooner than 90 days after providing notification to the
Chair of the Joint Legislative Budget Committee. This notification
shall articulate the specific reasons for the termination and shall
include all relevant data elements that are applicable to document
the reasons for the termination. Upon the request of the Chair of the
Joint Legislative Budget Committee, the board shall promptly provide
any additional clarifying information regarding implementation of
the processes required by this subdivision.
(g) By January 2008, the board, in consultation with stakeholders,
shall implement a process by which applicants self-certify income
and income deductions at the time of initial application. The board
shall request documentation and verify that information only to the
extent required under federal law.
SEC. 8. Section 12693.701 is added to the Insurance Code, to read:
12693.701. (a) (1) All children under 19 years of age who meet
the state residency requirements of the Medi-Cal program or the
Healthy Families Program shall be eligible for health care coverage
in accordance with subdivision (b) if they satisfy either of the
following criteria:
(A) Live in families with countable household income at or below
300 percent of the federal poverty level.
(B) Meet the income requirements of Section 14005.7 of the Welfare
and Institutions Code or the income and resource requirements of
Section 14005.30 of the Welfare and Institutions Code.
(2) The eligibility under paragraph (1) includes for both programs
all children for whom federal financial participation under Title
XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.),
or under Title XXI of the federal Social Security Act (42 U.S.C.
Sec. 1397aa et seq.) is not available because of their immigration
status or date of entry into the United States, but does not include
children who are ineligible for funds under those titles for other
reasons.
(b) Children described in subdivision (a) in families whose
household income would make them ineligible for the Medi-Cal program
with no share of cost or for Medicare, and who are in compliance with
Sections 12693.71 and 12693.72, shall be eligible for the Healthy
Families Program and shall also be eligible for the Medi-Cal program
with a share of cost in
accordance with Section 14005.7 of the Welfare and Institutions Code.
The remaining children described in subdivision (a) shall be
eligible for the Medi-Cal program with no share of cost.
(c) Nothing in this section shall be construed to authorize the
denial or reduction of medical assistance under the Medi-Cal program
(Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of
the Welfare and Institutions Code) or the Healthy Families Program
to a person who, without the application of this section, would
qualify for that assistance or to relieve the Medi-Cal program of the
obligation to determine eligibility on all other available grounds.
(d) The board shall implement this section, and children made
eligible for the program by this section shall be able to enroll in
the program, no later than January 1, 2008.
SEC. 9. Section 12693.73 of the Insurance Code is amended to read:
12693.73. Notwithstanding any other provision of law, children
excluded from coverage under Title XXI of the Social Security Act are
not eligible for coverage under the program, except as specified in
clause (ii) of subparagraph (A) of paragraph (5) of subdivision (a)
of Section 12693.70, Section 12693.701, and Section 12693.76.
SEC. 10. Section 12693.76 of the Insurance Code is amended to
read:
12693.76. (a) Notwithstanding any other provision of law, a child
shall not be determined ineligible solely on the basis of his or her
immigration status or date of entry into the United States.
(b) Notwithstanding any other provision of law, subdivision (a)
may only be implemented to the extent provided in the annual Budget
Act.
(c) Notwithstanding any other provision of law, an uninsured
parent or responsible adult who is a qualified alien, as defined in
Section 1641 of Title 8 of the United States Code, shall not be
determined to be ineligible solely on the basis of his or her date of
entry into the United States.
(d) Notwithstanding any other provision of law, subdivision (c)
may only be implemented to the extent of funding provided in the
annual Budget Act.
SEC. 11. Section 12693.98 of the Insurance Code is amended to
read:
12693.98. (a) (1) The Medi-Cal-to-Healthy Families Bridge
Benefits Program is hereby established to provide a child who meets
the criteria set forth in subdivision (b) with a one calendar-month
period of health care benefits in order to provide the child with an
opportunity to apply for the Healthy Families Program.
(2) The Medi-Cal-to-Healthy Families Bridge Benefits Program shall
be administered by the board and the State Department of Health Care
Services.
(b) (1) A child who meets all of the following requirements shall
be eligible for one calendar month of Healthy Families benefits
funded by Title XXI of the Social Security Act, known as the State
Children's Health Insurance Program:
(A) He or she has been receiving, but is no longer eligible for,
full-scope Medi-Cal benefits without a share of cost.
(B) He or she is eligible for full-scope Medi-Cal benefits with a
share of cost.
(C) He or she is under 19 years of age at the time he or she is no
longer eligible for full-scope Medi-Cal benefits without a share of
cost.
(D) He or she has family income at or below 200 percent of the
federal poverty level.
(E) He or she is not otherwise excluded under the definition of
"targeted low-income child" under subsections (b)(1)(B)(ii), (b)(1)
(C), and (b)(2) of Section 2110 of the Social Security Act (42 U.S.C.
Secs. 1397jj(b)(1)(B)(ii), 1397jj(b)(1)(C), and 1397jj(b)(2)).
(2) The one calendar month of benefits under this chapter shall
begin on the first day of the month following the last day of the
receipt of benefits without a share of cost.
(c) The income methodology for determining a child's family
income, as required by paragraph (1) of subdivision (b) shall be the
same methodology used in determining a child's eligibility for the
full scope of Medi-Cal benefits.
(d) The one calendar-month period of Healthy Families benefits
provided under this chapter shall be identical to the scope of
benefits that the child was receiving under the Medi-Cal program
without a share of cost.
(e) The one calendar-month period of Healthy Families benefits
provided under this chapter shall only be made available through a
Medi-Cal provider or under a Medi-Cal managed care arrangement or
contract.
(f) Except as provided in subdivision (j), nothing in this section
shall be construed to provide Healthy Families benefits for more
than a one calendar-month period under any circumstances, including
the failure to apply for benefits under the Healthy Families Program
or the failure to be made aware of the availability of the Healthy
Families Program, unless the circumstances described in subdivision
(b) reoccur.
(g) (1) This section shall become operative on the first day of
the second month following the effective date of this section,
subject to paragraph (2).
(2) Under no circumstances shall this section become operative
until, and shall be implemented only to the extent that, all
necessary federal approvals, including approval of any amendments to
the State Child Health Plan have been sought and obtained and federal
financial participation under the federal State Children's Health
Insurance Program, as set forth in Title XXI of the Social Security
Act, has been approved.
(h) This section shall become inoperative if an unappealable court
decision or judgment determines that any of the following apply:
(1) The provisions of this section are unconstitutional under the
United States Constitution or the California Constitution.
(2) The provisions of this section do not comply with the State
Children's Health Insurance Program, as set forth in Title XXI of the
Social Security Act.
(3) The provisions of this section require that the health care
benefits provided pursuant to this section are required to be
furnished for more than two calendar months.
(i) If the State Child Health Insurance Program waiver described
in Section 12693.755 is approved, and at the time the waiver is
implemented, the benefits described in this section shall also be
available to persons who meet the eligibility requirements of the
program and are parents of, or, as defined by the board, adults
responsible for, children enrolled to receive coverage under this
part or enrolled to receive full-scope Medi-Cal services with no
share of cost.
(j) The one month of benefits provided in this section shall be
increased to two months commencing on implementation of the waiver
referred to in Section 12693.755.
(k) This section shall cease to be implemented on the date that
the Director of Health Care Services executes a declaration stating
that implementation of the Medi-Cal to Healthy Families Presumptive
Eligibility Program established pursuant to Section 12693.98a has
commenced, and as of that date is repealed.
SEC. 12. Section 12693.98a of the Insurance Code is amended to
read:
12693.98a. (a) (1) The Medi-Cal to Healthy Families Presumptive
Eligibility Program is hereby established to provide a child who
meets the criteria set forth in subdivision (b) with presumptive
eligibility benefits until the board has determined the child's
eligibility for the Healthy Families Program.
(2) The Medi-Cal to Healthy Families Presumptive Eligibility
Program shall be administered by the board.
(b) (1) A child who meets both of the following requirements shall
be eligible for presumptive eligibility benefits under the Medi-Cal
to Healthy Families Presumptive Eligibility Program:
(A) He or she has been receiving, but is no longer eligible for,
full-scope Medi-Cal benefits without a share of cost, or he or she is
eligible for full-scope Medi-Cal benefits with a share of cost.
(B) He or she otherwise appears to meet the income eligibility
criteria for the Healthy Families Program.
(2) The presumptive eligibility benefits under this section shall
begin on the first day of the month following the last day of the
receipt of Medi-Cal benefits without a share of cost. Presumptive
eligibility benefits under this section shall terminate at the end of
the month in which a child's effective date in the Healthy Families
Program begins or the end of the month in which the board determines
that the child is not eligible for the Healthy Families Program. If
the board determines that the child is eligible for the Healthy
Families Program, the board shall enroll the child in the Healthy
Families Program without an interruption in coverage. If the board
determines that the child is ineligible for the Healthy Families
Program, the board shall terminate the child's benefits under the
Medi-Cal to Healthy Families Presumptive Eligibility Program.
(c) The income methodology for determining a child's family income
for the purposes of the Medi-Cal to Healthy Families Presumptive
Eligibility Program, as required by paragraph (1) of subdivision (b),
shall be the same methodology used in determining a child's
eligibility for the full scope of Medi-Cal benefits.
(d) The scope of presumptive eligibility benefits provided under
the Medi-Cal to Healthy Families Presumptive Eligibility Program
shall be identical to the scope of benefits that the child was
receiving under the Medi-Cal program without a share of cost.
(e) The presumptive eligibility benefits provided under this
section shall only be made available through a Medi-Cal provider or
under a Medi-Cal managed care arrangement or contract.
(f) When an application is forwarded by the county to the Healthy
Families Program, the county shall send the application to the
Healthy Families Program via an electronic application format defined
by the department, provided that the department has implemented the
automated interfaces necessary to accomplish electronic submission of
applications from the county to the Healthy Families Program without
requiring duplicative data entry by the county. The transmission of
the electronic application to the Healthy Families Program shall
occur within the timeframes designated by the department.
(g) To the extent necessary, the department and the board may
exchange a child's case file solely for the purpose of determining
the child's eligibility for the Medi-Cal program or the Healthy
Families Program, without requiring the family's consent, to the
extent allowed by federal law. Any information, including the child's
case file, shall be kept confidential by the department and the
board pursuant to state and federal law, and it shall be used only
for the determination or continuation of eligibility.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions, without taking any further
regulatory action. Thereafter, the department may adopt regulations,
as necessary, to implement this section in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.
(i) This section shall be implemented when the state has sought
and obtained approval of any amendments to its state plan necessary
to implement the changes to this section, pursuant to this act, and
has obtained funding under Title XXI of the Social Security Act (42
U.S.C. Sec. 1397aa et seq.) for the provision of benefits under this
section. Until the changes to this section, made by this act, are
implemented, the Medi-Cal to Healthy Families Bridge Program
established pursuant to Section 12693.98 shall remain in effect.
Notwithstanding any other provision of law, and only when all
necessary federal approvals have been obtained by the state, this
section shall be implemented only to the extent federal financial
participation under Title XXI of the Social Security Act (42 U.S.C.
Sec. 1397aa et seq.) is available to fund benefits provided under
this section.
(j) Upon implementation of the Medi-Cal to Healthy Families
Presumptive Eligibility Program pursuant to this section, the
Director of Health Care Services shall execute a declaration, which
shall be retained by the director, stating that implementation of the
section has commenced.
SEC. 13. Section 12693.981 of the Insurance
Code is amended to read:
12693.981. (a) (1) The Healthy Families-to-Medi-Cal Bridge
Benefits Program is hereby established to provide any person enrolled
for coverage under this part who meets the criteria set forth in
subdivision (b) with a two calendar-month period of health care
benefits in order to provide the person with an opportunity to apply
for Medi-Cal.
(2) The Healthy Families-to-Medi-Cal Bridge Benefits Program shall
be administered by the board.
(b) (1) Any person who meets all of the following requirements
shall be eligible for two additional calendar months of Healthy
Families benefits:
(A) He or she has been receiving, but is no longer eligible for,
benefits under the program.
(B) He or she appears to be income eligible for full-scope
Medi-Cal benefits without a share of cost.
(2) The two additional calendar months of benefits under this
chapter shall begin on the first day of the month following the last
day of the person's eligibility for benefits under the program.
(c) The two-calendar-month period of Healthy Families benefits
provided under this chapter shall be identical to the scope of
benefits that the person was receiving under the program.
(d) Nothing in this section shall be construed to provide Healthy
Families benefits for more than a two calendar-month period under any
circumstances, including the failure to apply for benefits under the
Medi-Cal program or the failure to be made aware of the availability
of the Medi-Cal program unless the circumstances described in
subdivision (b) reoccur.
(e) This section shall become inoperative if an unappealable court
decision or judgment determines that any of the following apply:
(1) The provisions of this section are unconstitutional under the
United States Constitution or the California Constitution.
(2) The provisions of this section do not comply with the State
Children's Health Insurance Program, as set forth in Title XXI of the
federal Social Security Act.
(3) The provisions of this section require that the health care
benefits provided pursuant to this section are required to be
furnished for more than two calendar months.
(f) This section shall become inoperative on the date that the
board executes a declaration stating that the implementation of the
Healthy Families to Medi-Cal Presumptive Eligibility Program
established pursuant to Section 12693.981a has commenced. As of the
next occurring January 1, this section is repealed, unless a later
enacted statute, enacted before that January 1 date, deletes or
extends the dates on which this section becomes inoperative and is
repealed.
SEC. 14. SEC. 13. Section 12693.981a
is added to the Insurance Code, to read:
12693.981a. (a) The Healthy Families to Medi-Cal Presumptive
Eligibility Program is hereby established to provide a child who
meets the criteria set forth in subdivision (c) with presumptive
eligibility benefits until the child's eligibility for full scope
Medi-Cal benefits with no share of cost has been determined.
(b) The Healthy Families to Medi-Cal Presumptive Eligibility
Program shall be administered by the board.
(c) A child who meets both of the following requirements shall be
eligible for presumptive eligibility benefits under the Healthy
Families to Medi-Cal Presumptive Eligibility Program:
(1) He or she has been receiving, but is no longer eligible for,
benefits under the Healthy Families Program.
(2) He or she otherwise appears to be income eligible for
full-scope Medi-Cal benefits with no share of cost.
(d) The presumptive eligibility benefits under this section shall
begin on the first day of the month following the board's
determination that the child is no longer eligible for the Healthy
Families Program. To prevent an interruption in coverage, benefits
under the Healthy Families Program shall continue until the end of
the month in which that determination is made.
(1) If the county determines that the child is eligible for the
Medi-Cal program, the county shall enroll the child in the Medi-Cal
program without an interruption in coverage. The presumptive
eligibility benefits under this section shall terminate on the last
day of the month that precedes the month in which the child begins
receiving benefits under the Medi-Cal program.
(2) If the county determines that the child is ineligible for the
Medi-Cal program, with or without a share of cost, the county shall
terminate the child's benefits under the Healthy Families to Medi-Cal
Presumptive Eligibility Program in accordance with due process
requirements.
(e) The income methodology for determining a child's family income
for the purposes of the Healthy Families to Medi-Cal Presumptive
Eligibility Program, as required by subdivision (c), shall be the
same methodology used in determining a child's eligibility for the
full scope of Medi-Cal benefits.
(f) The scope of presumptive eligibility benefits provided under
the Healthy Families to Medi-Cal Presumptive Eligibility Program
shall be identical to the full scope of benefits under the Medi-Cal
program.
(g) No family contribution is required for a child receiving
presumptive eligibility benefits under the Healthy Families to
Medi-Cal Presumptive Eligibility Program.
(h) To the extent necessary and to the extent allowed by federal
law, the State Department of Health Care Services, counties, and the
board may exchange a child's case file solely for the purpose of
determining the child's eligibility for the Medi-Cal program or the
Healthy Families Program, without requiring the family's consent. Any
information, including the child's case file, shall be kept
confidential by the department and the board in accordance with the
confidentiality and privacy protections set forth in Sections 10500
and 14100.2 of the Welfare and Institutions Code.
(i) The board shall develop, in consultation with consumer
advocates and other stakeholders, a system for tracking cases where
children receive benefits under the Healthy Families to Medi-Cal
Presumptive Eligibility Program for more than two months and for
followup of those cases. The followup system shall include the
following activities to ensure that children in the Healthy Families
to Medi-Cal Presumptive Eligibility Program are enrolled in a timely
manner into the ongoing health care benefits program for which they
are eligible:
(1) The board shall identify those cases where children are
enrolled in the Healthy Families to Medi-Cal Presumptive Eligibility
Program for more than two months and report those cases to the
department. The department shall consult with the counties to
determine the status of each case and provide support and technical
assistance to assist the counties to take the necessary actions to
complete the eligibility determination process for each child to
obtain the ongoing health care benefits for which the child is
eligible.
(2) If children in the Healthy Families to Medi-Cal Presumptive
Eligibility Program are denied enrollment in the Medi-Cal program,
the board shall contact the State Department of Health Care Services
or the county where the child resides in order to work with the
county to enroll the child in the program for which he or she is
eligible.
(j) Upon implementation of the Healthy Families to Medi-Cal
Presumptive Eligibility Program pursuant to this section, the board
shall execute a declaration, which it shall retain, stating that
implementation of the section has commenced.
SEC. 15. SEC. 14. Section 12693.983
is added to the Insurance Code, to read:
12693.983. (a) The board and the State Department of Health Care
Services shall monitor the Medi-Cal to Healthy Families Presumptive
Eligibility Program in Section 12693.98a and the Healthy Families to
Medi-Cal Presumptive Eligibility Program in Section 12693.981a in
order to ensure that all children are enrolled in a timely manner in
the presumptive eligibility benefits for which they are eligible.
(b) The monitoring responsibilities required by this section shall
consist of the following activities:
(1) The board and the department shall collect and make publicly
available on their respective Internet Web sites the following data
on a quarterly basis:
(A) The number of children enrolled in the Medi-Cal to Healthy
Families Presumptive Eligibility Program and the number of children
enrolled in the Healthy Families to Medi-Cal Presumptive Eligibility
Program.
(B) The length of time these children were enrolled in each
program.
(C) The status of the children enrolled in each program, including
a status report for each child enrolled more than one month in the
Medi-Cal to Healthy Families Presumptive Eligibility Program and more
than two months in the Healthy Families to Medi-Cal Presumptive
Eligibility Program.
(2) The board and the department shall record all attempts to
assist the child to enroll in ongoing health benefits programs and
shall record the final disposition of the child's application for
continuing health coverage.
(c) The department shall work with the Managed Risk Medical
Insurance Board, counties, and client advocates to document and
identify barriers to timely eligibility determination and
discontinuance of accelerated benefits for children and to implement
methods to overcome those barriers. The department, in consultation
with the Managed Risk Medical Insurance Board, counties, and client
advocates, shall provide written recommendations to the Secretary of
California Health and Human Services on how to ensure timely
eligibility determinations for children enrolled in accelerated
enrollment and presumptive eligibility programs and shall work with
stakeholders and consumer advocates to implement those
recommendations.
SEC. 16. SEC. 15. Section 12694 of
the Insurance Code is amended to read:
12694. (a) The board and the department, in collaboration with
program offices for the California Special Supplemental Food Program
for Women, Infants, and Children (WIC or the WIC program), local WIC
agencies, counties in their capacity of making Medi-Cal eligibility
determinations, advocates, information technology specialists, and
other stakeholders, shall design, promulgate, and implement policies
and procedures for an automated enrollment gateway system developed
by the department and the board that performs, but is not limited to
performing, the following functions:
(1) To the extent that federal financial participation is
available, allowing children applying to the WIC program to submit a
simple electronic application to simultaneously obtain presumptive
eligibility for Medi-Cal and Healthy Families under Title XIX (42
U.S.C. Sec. 1396 et seq.) and Title XXI (42 U.S.C. Sec. 1397aa et
seq.) of the Social Security Act and apply for enrollment into the
Medi-Cal program or the Healthy Families Program with the consent of
their parent or guardian.
(2) Modify the existing WIC enrollment system to obtain the
minimum required data for enrollment in the Medi-Cal program and the
Healthy Families Program in order to provide an electronic
transactional platform that is connected to the simple electronic
application referenced in paragraph (1) and allowing for an interface
between that application, the Medi-Cal Eligibility Data System
(MEDS), and the Medi-Cal program or the Healthy Families Program, as
relevant.
(3) Providing an automated real-time connection with MEDS for the
purpose of checking an applicant's enrollment status.
(4) Allowing for the electronic transfer of information to the
Medi-Cal program or the Healthy Families Program, as relevant, for
the purpose of making the final eligibility determination.
(5) Checking, as relevant, available government databases for the
purpose of electronically receiving information that is necessary to
allow the Medi-Cal program or the Healthy Families Program to
complete the eligibility determination. The department and the
Managed Risk Medical Insurance Board shall comply with all applicable
privacy and confidentiality provisions under federal and state law.
(b) The automated enrollment gateway system shall be constructed
with the capacity to be used by entities operating the WIC program.
(c) The WIC application process shall be modified to provide an
electronic application described in subdivision (a), which shall
contain the information necessary to apply for the automated
enrollment gateway system, supplemented by information required to
apply for enrollment into the Medi-Cal program or the Healthy
Families Program.
(d) Benefits for applicants opting to simultaneously obtain
presumptive eligibility for enrollment under this section shall
continue until a final eligibility determination is made for the
Medi-Cal program or the Healthy Families Program pursuant to Section
14011.8 of the Welfare and Institutions Code.
(e) Operation of the automated enrollment gateway system for the
WIC program shall occur within a timely and appropriate period as
determined by the department and the board, in consultation with the
stakeholders as provided in subdivision (a), subject to a specific
appropriation being provided for that purpose in the Budget Act or in
subsequent legislation. The automated enrollment gateway system
shall comply with all applicable confidentiality and privacy
protection in federal and state law and regulation.
(f) The WIC program shall collect income and residency information
necessary for the Medi-Cal program and the Healthy Families Program
documentation requirements for applications submitted through the
automated enrollment gateway system. To the extent allowed by the
federal government, the Medi-Cal and Healthy Families programs shall
rely on income information obtained by WIC and upon the income
verification process performed by WIC. The Medi-Cal and Healthy
Families programs shall collect and verify citizenship and
immigration information as required under
those programs.
(g) Consistent with the provisions of this section, the Medi-Cal
and Healthy Families programs may collect additional information
needed to verify eligibility in those programs.
(h) Counties shall accept and process for a Medi-Cal eligibility
determination applications provided by the WIC gateway system and
ensure timely processing of these applications and a timely
eligibility determination and ending of presumptive eligibility.
(i) The presumptive eligibility benefits provided under this
section shall be identical to the benefits provided to children who
receive full-scope Medi-Cal benefits without a share of cost, and
shall only be made available through a Medi-Cal provider.
(j) The confidentiality and privacy protections set forth in
Sections 10850 and 14100.2 of the Welfare and Institutions Code and
all other confidentiality and privacy protections in federal and
state law and regulation shall apply to all children and families
using the automated enrollment gateway system as described in this
section.
(k) The state shall promote and offer support to the WIC program
for the use of the simple electronic application and the automated
enrollment gateway system.
(l) The board shall seek approval of any amendments to the state
plan necessary to implement this section, in accordance with Title
XXI (42 U.S.C. Sec. 1397aa et seq.) of the federal Social Security
Act.
(m) The department shall seek approval of any amendments to the
state plan necessary to implement this section, in accordance with
Title XIX (42 U.S.C. Sec. 1396 et seq.) of the federal Social
Security Act. Notwithstanding any other provision of law, only when
all necessary federal approvals have been obtained shall this section
be implemented.
(n) Use of the automated enrollment gateway system by an entity
shall be required only to the extent that sufficient financial
assistance, which may be provided by public or private sources, is
made available to support the additional training, staff time,
administration, and other expenditures required by the entity to use
the automated enrollment gateway systems.
SEC. 17. SEC. 16. Chapter 16.2
(commencing with Section 12694.1) is added to Part 6.2 of Division 2
of the Insurance Code, to read:
CHAPTER 16.2. HEALTHY FAMILIES BUY-IN PROGRAM
12694.1. On or after ____, the board shall implement the Healthy
Families Buy-In Program that shall be referred to as the buy-in
program for purposes of this chapter.
12694.2. A child under 19 years of age is eligible for the buy-in
program if he or she meets all of the following criteria:
(a) Lives in a family whose monthly or annual income exceeds 300
percent of the federal poverty level.
(b) Is not eligible for full scope Medi-Cal benefits without a
share of cost or the Healthy Families Program.
(c) Has been without health care coverage for, at minimum, a
period of six consecutive months immediately preceding the date of
application for the buy-in program. Compliance with this criteria
shall be determined by the board using the same verification
procedures that it uses to verify compliance with Sections 12693.71
and 12693.72.
12694.4. The coverage for children in the buy-in program shall be
identical to the coverage for children enrolled in the Healthy
Families Program and shall include health, dental, and vision
benefits provided solely by a participating health, dental, or vision
care plan. Coverage shall also include the services provided
pursuant to the California Children's Services Program (Article 5
(commencing with Section 123800) of Chapter 3 of Part 2 of Division
106 of the Health and Safety Code) for a child who has been found
eligible for that program.
12694.5. (a) The family of a child enrolled in the buy-in program
shall pay the board a monthly contribution amount that equals the
full cost of coverage for health, dental, and vision benefits for the
child under the Healthy Families Program. The family of a child
enrolled in the buy-in program who has been determined eligible for
the California Children's Services Program shall also pay the board
the average monthly cost of providing services to a child pursuant to
the California Children's Services Program, as calculated annually
by the board in consultation with the California Children's Services
Program based on its operational experience.
(b) The family of a child enrolled in the buy-in program shall
receive the same discounts from their contributions under this
section as provided to applicants pursuant to paragraph (4) of
subdivision (d) of, and subdivisions (e) and (f) of, Section 12693.43
and shall be subject to the payment procedures set forth in Section
2699.6813 of Title 10 of the California Code of Regulations.
12694.6. (a) A county that determines a child ineligible for the
Medi-Cal program or for the Healthy Families Program shall inform the
applicant of the option of enrolling the child in the buy-in program
and, with the applicant's approval, shall transmit the application
to the board.
(b) If the board determines a child is ineligible for the Healthy
Families Program or the Medi-Cal program, it shall inform the
applicant of the option of enrolling the child in the buy-in program
and, with the applicant's approval, shall consider the application
for the child's eligibility for the buy-in program.
SEC. 18. SEC. 17. Section 14005.23
of the Welfare and Institutions Code is amended to read:
14005.23. (a) To the extent federal financial participation is
available, the department shall, when determining eligibility for
children under Section 1396a()(1)(D) of Title 42 of the United States
Code, designate a birth date by which all children who have not
attained the age of 19 years will meet the age requirement of Section
1396a()(1)(D) of Title 42 of the United States Code.
(b) On and after January 1, 2008, the department shall apply the
less restrictive income deduction described in Section 1396a(r) of
Title 42 of the United States Code when determining eligibility for
the children identified in Section 14005.26. The amount of this
deduction shall be the difference between 133 percent and 100 percent
of the federal poverty level applicable to the size of the family.
SEC. 19. SEC. 18. Section 14005.26
is added to the Welfare and Institutions Code, to read:
14005.26. (a) Children, including children for whom federal
financial participation is not available under Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) for
full-scope coverage, who meet the household income and age
requirements in Section 14005.23 shall be eligible to enroll in the
Medi-Cal program.
(b) When determining the eligibility of children described in
subdivision (a), the department shall apply the less restrictive
income disregard described in Section 1396a(r) of Title 42 of the
United States Code. The income disregard shall be equal to the
difference between the income standard and the amount equal to 133
percent of the federal poverty level applicable to the family size.
(c) Nothing in this section shall be construed to authorize the
denial, discontinuance, or reduction of medical assistance under the
Medi-Cal program or the Healthy Families Program (Part 6.2
(commencing with Section 12693) of Division 2 of the Insurance Code)
to a person who qualifies for the Medi-Cal program or for the Healthy
Families Program, or who, without the application of this section,
would qualify for either program, or to relieve the Medi-Cal program
or the Healthy Families Program of the obligation to determine
eligibility on all other available grounds.
SEC. 20. SEC. 19. Section 14011.01
is added to the Welfare and Institutions Code, to read:
14011.01. (a) The department, in coordination with the Managed
Risk Medical Insurance Board, counties, consumer advocates, and other
stakeholders, shall make technological improvements to the existing
eligibility determination and enrollment systems for the Medi-Cal
program, such as the Medi-Cal Eligibility Data System (MEDS), the
Statewide Automated Welfare System, and the Healthy Families Program
based on the guidelines set forth in subdivisions (b), (c), and (d)
in order to better integrate the enrollment processes for those
programs.
(b) The improvements shall allow families to be screened for, and
with their consent to apply to, multiple programs from more than one
location.
(c) The improvements shall include, but not be limited to,
accomplishment of all of the following objectives:
(1) Promote accessible enrollment opportunities through public
service programs that are widely used by families, including schools,
and other public access points, while incorporating mechanisms to
minimize duplicate applications and to identify whether a child is
currently enrolled in the Medi-Cal program, the Healthy Families
Program, or other coverage before processing a new application.
(2) Eliminate all duplicative requests and requirements for
applications and other information and require the Managed Risk
Medical Insurance Board, the department, and the counties to use the
procedures in subdivisions (e) to (g), inclusive, of Section 14005.37
for all applications to minimize the burdens on families.
(3) Support electronic and digital signature approaches to reduce
the burden of the applicant appearing in person and to allow the
applicant to submit any application without appearing in person,
wherever possible.
(4) Eliminate all documentation requirements, other than those
required by federal law, and verify necessary information through
other available databases and through the use of the procedures
established in subdivisions (e) to (g), inclusive, of Section
14005.37.
(5) Promote data integrity by expanding access to and improving
MEDS search and file clearance functionality.
(6) Include the ability to obtain birth and other state maintained
verification documents electronically.
(7) Support electronic exchange of information with the Statewide
Automated Welfare System.
(8) Guarantee privacy protections and secure information exchange.
(d) To improve the integration and efficiency of technological
systems used by the state to operate the Medi-Cal program and the
Healthy Families Program, the department shall take the following
actions:
(1) Establish reusable service-based interfaces to allow multiple
existing enrollment systems to exchange data electronically.
(2) Support the electronic submission of verification documents
that are also available for exchange and reuse by multiple existing
enrollment systems.
(3) Develop a plan and timeline for the implementation of
technology that provides an infrastructure to allow legacy systems,
new enrollment systems, and other systems to access common system
functions, features, and rules through a central repository of shared
services.
SEC. 21. SEC. 20. Section 14011.61
is added to the Welfare and Institutions Code, to read:
14011.61. (a) To the extent allowed under Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and Title
XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et
seq.), and to the extent federal financial participation is available
under Title XXI of the federal Social Security Act, the department
shall administer the Medi-Cal Presumptive Eligibility Program to
provide a child who meets the criteria set forth in subdivision (d)
with presumptive eligibility benefits for the period described in
subdivision (g).
(b) The department shall designate all 58 counties as qualified
entities for determining eligibility under this section.
(c) A county shall perform an initial screen of every application
for the Medi-Cal program or the Healthy Families Program that is
filed with that county. The initial screen shall be completed within
48 hours from the time of submission of the application for the
Medi-Cal program or the Healthy Families Program.
(d) On the basis of the initial screen performed by the county, a
child who meets all of the following requirements shall be eligible
for presumptive eligibility benefits under this section:
(1) The child, or his or her parent or guardian, submits an
application for the Medi-Cal program or the Healthy Families Program
directly to the county.
(2) The child's income, as screened by the county on the basis of
the application described in paragraph (1), appears to be within the
income levels necessary to establish eligibility for the Medi-Cal
program with no share of cost.
(3) The child is under 19 years of age at the time of the
application.
(4) The child is not receiving no-cost Medi-Cal benefits or
benefits under the Healthy Families Program at the time that the
application is submitted.
(e) When the county performs the initial screen and determines
that the child meets the criteria described in subdivision (d), the
county shall immediately establish presumptive eligibility for the
Medi-Cal program for that child. The presumptive eligibility benefits
provided under this section shall be identical to the benefits
provided to children who receive full-scope Medi-Cal benefits with no
share of cost and shall only be made available through a Medi-Cal
program provider.
(f) Once presumptive eligibility has been established, the county
shall continue to determine a child's eligibility for the Medi-Cal
program on the basis of the application submitted to it.
(g) The period of presumptive eligibility provided for under this
section begins on the first day of the month that the application is
filed.
(h) If the county determines that the child is eligible for the
Medi-Cal program without a share of cost, the county shall enroll the
child in the Medi-Cal program without an interruption in coverage.
If the county determines that the child is eligible for the Medi-Cal
program with a share of cost, the county shall enroll the child in
the Medi-Cal program and forward the application to the Managed Risk
Medical Insurance Board for an evaluation of the child's eligibility
for the Healthy Families Program. To ensure continuity of coverage,
the presumptive eligibility benefits under this section shall
terminate on the last day of the month that precedes the month in
which the child begins receiving benefits under the Medi-Cal program.
(i) If the county determines that the child is ineligible for the
Medi-Cal program with or without a share of cost, the county shall
terminate the child's presumptive eligibility benefits under this
section in accordance with due process requirements.
(j) The Managed Risk Medical Insurance Board and the department,
in consultation with counties, consumer advocates, and other
stakeholders, shall develop a notice to inform families of the
transfer of a case between the Medi-Cal program and the Healthy
Families Program and from presumptive eligibility benefits to
benefits under one of those programs, to minimize the confusion for
the family, to clarify that coverage is continued during the
transfer, and to provide the family with contact information advising
the family where to ask questions about continuity of coverage and
access to care.
(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions, without taking any further
regulatory action. Thereafter, the department shall adopt
regulations, as necessary, to implement this section in accordance
with the requirements of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code.
(l) The department, in consultation with representatives of the
local agencies that administer the Medi-Cal program, consumer
advocates, and other stakeholders, shall develop and distribute the
policies and procedures, including any all-county letters, necessary
to implement this section.
(m) Nothing in this section shall be construed to authorize the
denial of medical assistance under the Medi-Cal program to a child
who, without the application of this section, would qualify for that
assistance or to excuse the Medi-Cal program or the Healthy Families
Program of the obligation to determine eligibility on all other
available grounds.
(n) The department shall begin to implement this section on
January 1, 2008.
SEC. 22. SEC. 21. Section 14011.65
of the Welfare and Institutions Code is amended to read:
14011.65. (a) To the extent allowed under federal law and only if
federal financial participation is available under Title XXI of the
Social Security Act (42 U.S.C. Sec. 1397aa et seq.), the state shall
administer the Medi-Cal to Healthy Families Accelerated Enrollment
program, to provide any child who meets the criteria set forth in
subdivision (b) with temporary health benefits for the period
described in paragraph (2) of subdivision (b), as established under
Part 6.2 (commencing with Section 12693) of Division 2 of the
Insurance Code.
(b) (1) Any child who meets all of the following requirements,
shall be eligible for temporary health benefits under this section:
(A) The child, or his or her parent or guardian, submits an
application for the Medi-Cal program directly to the county.
(B) The child's income, as determined on the basis of the
application described in subparagraph (A), is within the income
limits established by the Healthy Families Program.
(C) The child is under 19 years of age at the time of the
application.
(D) The county determines, on the basis of the application
described in subparagraph (A), that the child is eligible for full
scope Medi-Cal with a share of cost.
(E) The child is not receiving Medi-Cal benefits at the time that
the application is submitted.
(F) The child, or his or her parent or guardian, gives or has
given consent for the application to be shared with the Healthy
Families Program for purposes of determining the child's Healthy
Families Program eligibility.
(2) The period of accelerated eligibility provided for under this
section begins on the first day of the month that the county finds
that the child meets all of the criteria described in paragraph (1)
and concludes on the last day of the month that the child either is
fully enrolled in, or has been determined ineligible for, the Healthy
Families Program.
(3) For any child who meets the requirements for temporary health
benefits under this section, the county shall forward to the Healthy
Families Program sufficient information from the child's application
to determine eligibility for the Healthy Families Program. To the
extent possible, submission of that information to the Healthy
Families Program shall be accomplished using an electronic process
developed for use in the Medi-Cal-to-Healthy Families Bridge Benefits
Program. The department shall give the Healthy Families Program a
daily electronic file of all children provided temporary health
benefits pursuant to this section.
(4) The temporary health benefits provided under this section
shall be identical to the benefits provided to children who receive
full-scope Medi-Cal benefits without a share of cost and shall only
be made available through a Medi-Cal provider.
(c) The department, in consultation with the Managed Risk Medical
Insurance Board and representatives of the local agencies that
administer the Medi-Cal program, consumer advocates, and other
stakeholders, shall develop and distribute the policies and
procedures, including any all-county letters, necessary to implement
this section.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions, without taking any further
regulatory action. Thereafter, the department may adopt regulations,
as necessary, to implement this section in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.
(e) The department shall seek approval of any amendments to the
state plan necessary to implement this section, in accordance with
Title XIX (42 U.S.C. Sec. 1396 et seq.) of the Social Security Act.
Notwithstanding any other provision of law, only when all necessary
federal approvals have been obtained shall this section be
implemented.
(f) Under no circumstances shall this section be implemented
unless the state has sought and obtained approval of any amendments
to its state plan, as described in Section 12693.50 of the Insurance
Code, necessary to implement this section and obtain funding under
Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et seq.)
for the provision of benefits provided under this section.
Notwithstanding any other provision of law, and only when all
necessary federal approvals have been obtained by the state, this
section shall be implemented only to the extent federal financial
participation under Title XXI of the Social Security Act (42 U.S.C.
Sec. 1397aa et seq.) is available to fund benefits provided under
this section.
(g) The department shall commence implementation of this section
on the first day of the third month following the month in which
federal approval of the state plan amendment or amendments described
in subdivision (f), and subdivision (b) of Section 12693.50 of the
Insurance Code is received, or on August 1, 2006, whichever is later.
(h) This section shall cease to be implemented on the date that
the director executes a declaration, pursuant to subdivision (h) of
Section 14011.65a, stating that implementation of that section has
commenced.
SEC. 23. SEC. 22. Section 14011.65a
of the Welfare and Institutions Code is amended to read:
14011.65a. (a) To the extent allowed under federal law under
Title XIX (42 U.S.C. Sec. 1396 et seq.) and Title XXI (42 U.S.C. Sec.
1397aa et seq.) of the Social Security Act, and only if federal
financial participation is available under Title XXI (42 U.S.C. Sec.
1397aa et seq.) of the Social Security Act, the state shall
administer the Healthy Families Presumptive Eligibility Program, to
provide any child who meets the criteria set forth in subdivision (b)
with presumptive eligibility benefits for the period described in
paragraph (4) of subdivision (b).
(b) (1) On the basis of an initial screen performed by the county
when an application for Medi-Cal or Healthy Families Program
eligibility is filed, any child who meets all of the following
requirements, shall be eligible for presumptive eligibility benefits
under this section:
(A) The child, or his or her parent or guardian, submits an
application for the Medi-Cal program or the Healthy Families Program
directly to the county.
(B) The child's income, as screened by the county on the basis of
the application described in subparagraph (A), is not within the
income levels necessary to establish no share-of-cost Medi-Cal
eligibility.
(C) The child's income, as screened by the county on the basis of
the application described in subparagraph (A), is within the income
limits established by the Healthy Families Program.
(D) The child is under 19 years of age at the time of the
application.
(E) The child is not receiving no-cost Medi-Cal or Healthy
Families Program benefits at the time that the application is
submitted.
(2) When the county performs the initial screen and determines
that the child meets the criteria described in paragraph (1), the
county shall establish presumptive eligibility for the Healthy
Families Program for that child. Once presumptive eligibility has
been established, the county shall continue to determine the child's
eligibility for the Medi-Cal program on the basis of the filed
application.
(3) When the county completes the Medi-Cal eligibility
determination process and determines a child ineligible for no-cost
Medi-Cal and the child appears to be income eligible for the Healthy
Families Program, the county shall find the child presumptively
eligible for the Healthy Families Program and comply with the
standards set forth in paragraph (5) if either of the following
conditions are met:
(A) The county determined the child eligible for Medi-Cal with a
share of cost.
(B) The child is not income eligible for a poverty level program
and the county did not establish no-cost Medi-Cal eligibility because
the child did not complete or failed to pass the resource standard
or establish disability or deprivation.
(4) The period of presumptive eligibility provided for under this
section begins on the first day of the month that the county finds
that the child meets all of the criteria described in paragraph (1)
or (3), and concludes on the last day of the month of the child's
effective date of coverage in the Healthy Families Program, or
determination of ineligibility for the Healthy Families Program.
(5) (A) For any child who meets the requirements for presumptive
eligibility benefits under this section, the county shall forward to
the Healthy Families Program the child's application, to determine
eligibility for the Healthy Families Program. The submission of the
application to the Healthy Families Program shall be accomplished
using an electronic format, specified by the department provided that
the department has implemented the automated interfaces necessary to
accomplish electronic submission of applications from the county to
the Healthy Families Program without requiring duplicative data entry
by the county. If all of the eligibility criteria set forth in
paragraph (1) of subdivision (b) are established at the time of
application, the application to the Healthy Families Program shall be
forwarded in accordance with the timeframes established by the
department.
(B) The department shall give the Healthy Families Program a daily
electronic file of all children provided presumptive eligibility
benefits pursuant to this section.
(6) The presumptive eligibility benefits provided under this
section shall be identical to the benefits provided to children who
receive full-scope Medi-Cal benefits without a share of cost and
shall only be made available through a Medi-Cal provider.
(c) The department, in consultation with the Managed Risk Medical
Insurance Board and representatives of the local agencies that
administer the Medi-Cal program, consumer advocates, and other
stakeholders, shall develop and distribute the policies and
procedures, including any all-county letters, necessary to implement
this section.
(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions, without taking any further
regulatory action. Thereafter, the department may adopt regulations,
as necessary, to implement this section in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.
(e) The department shall seek approval of any amendments to the
state plan necessary to implement this section, in accordance with
Title XIX (42 U.S.C. Sec. 1396 et seq.) of the Social Security Act.
Notwithstanding any other provision of law, only when all necessary
federal approvals have been obtained shall this section be
implemented.
(f) Under no circumstances shall this section be implemented
unless the state has sought and obtained approval of any amendments
to its state plan, as described in Section 12693.50 of the Insurance
Code, necessary to implement this section and obtain funding under
Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et seq.)
for the provision of benefits provided under this section.
Notwithstanding any other provision of law, and only when all
necessary federal approvals have been obtained by the state, this
section shall be implemented only to the extent federal financial
participation under Title XXI of the Social Security Act (42 U.S.C.
Sec. 1397aa et seq.) is available to fund benefits provided under
this section.
(g) The department shall commence implementation of this section
on the first day of the third month following the month in which
federal approval of the state plan amendment or amendments described
in subdivision (f), and subdivision (b) of Section 12693.50 of the
Insurance Code is received, or on August 1, 2007, whichever is later.
(h) Upon implementation of the Healthy Families Presumptive
Eligibility Program pursuant to this section, the director shall
execute a declaration, which shall be retained by the director,
stating that implementation of this section has commenced.
SEC. 24. SEC. 23. Notwithstanding
any other provision of law, the Managed Risk Medical Insurance Board
may implement the provisions of this act expanding the Healthy
Families Program only to the extent that funds are appropriated for
those purposes in the annual Budget Act or in another statute.
SEC. 24. Section 2.5 of this bill incorporates
amendments to Section 123870 of the Health and Safety Code proposed
by both this bill and SB 137. It shall only become operative if (1)
both bills are enacted and become effective on or before January 1,
2008, (2) each bill amends Section 123870 of the Health and Safety
Code, and (3) this bill is enacted after SB 137, in which case
Section 2 of this bill shall not become operative.
SEC. 25. If the Commission on State Mandates determines that this
act contains costs mandated by the state, reimbursement to local
agencies and school districts for those costs shall be made pursuant
to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of
the Government Code.
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